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PubMed1998

Pelvic floor dyssynergia and bimodal rehabilitation: results of combined pelviperineal kinesitherapy and biofeedback training.

Dyschezia may be caused by pelvic floor dyssynergia, which takes place when a paradoxical contraction or a failure to relax the pelvic floor muscles occurs during attempts to defecate. The aim of our study was to set up a new bimodal rehabilitation programme for pelvic floor dyssynergia, which combined pelviperineal kinesitherapy and biofeedback, and to evaluate the results of this treatment. Thirty-five patients (age range: 28-64 years; mean age: 42.5 years) from the outpatient unit of the Clinica Chirurgica of the University of Florence, Italy, and an age-matched group of 10 healthy control subjects (age range: 31-59 years; mean age 45.7 years) with normal bowel habits and without any defecatory disorders, were studied. The 35 patients were symptomatic for dyschezia without slow colonic transit and had been diagnosed as being affected by pelvic floor dyssynergia. No evidence of any organic aetiology was present but all demonstrated both manometric and radiological evidence of inappropriate function of the pelvic floor. All of the patients underwent bimodal rehabilitation, using the combined training programme Clinical evaluation, computerized anorectal manometry and defecography were carried out 1 week before and 1 week after a completed course in bimodal rehabilitation. The control group underwent manometric and defecographic examination. Their results were compared with those of the 35 patients before and after training. After the programme, all 35 patients had a very significant increase in stool frequency (P < 0.001), while laxative and enema-induced bowel movements had become significantly less frequent (P < 0.001). After bimodal rehabilitation, computerized anorectal manometry showed some peculiar results. Resting anal canal pressure had increased but not significantly. Pre-programme values that indicated a shorter duration ("exhaustio") of maximal voluntary contraction than found in the controls had returned to normal values. The rectoanal inhibitory reflex (RAIR), with incomplete relaxation, which had been shorter than that of controls, became normal by the end of the rehabilitation. All RAIR parameters were significantly different especially when pre- and post-treatment values were compared (P < 0.001). No differences were found as regards rectal sensation parameters and rectal compliance between those before or after bimodal rehabilitation. Defecographic pretreatment X-ray films showed indentation of the puborectalis and poor anorectal angle (ARA) opening, at evacuation, with trapping barium of at 50%. After pelviperineal kinesitherapy and biofeedback training, the indentation had disappeared and the ARA had become significantly larger (P < 0.001) during evacuation. No differences were found after rehabilitation, when both were compared with those of controls. The pelvic floor descent was also significantly deeper (P < 0.001) than before the start of the programme. The bimodal rehabilitation technique can be considered a useful therapeutic option for functional dyschezia as shown by our clinical evaluations, manometric data and defecographic reports.

Adult↗
PubMed1999

Resection rectopexy for rectal prolapse. The laparoscopic approach.

BACKGROUND: Resection rectopexy through open laparotomy is an established procedure for the treatment of rectal prolapse. METHODS: Resection rectopexy was successfully performed in 10 multiparous women by the laparoscopic approach (LAP), and the results were compared to those of eight women with laparotomy resection rectopexy (OPEN). Preoperative and postoperative assessment included anorectal manometry, defecography, and measurement of large-bowel transit. RESULTS: The duration of the operation was longer in the LAP than in the OPEN group (p < 0.01). Morbidity was lower (p < 0.01) and hospital stay was shorter (p < 0.001) after the LAP than in the OPEN group. Prolapse was cured in all cases. Postoperatively, anal resting and squeeze pressures and rectal compliance increased significantly in both groups of patients (p = 0.007, p = 0.003, and p < 0.001, respectively). In all patients, the operation resulted in acceleration of large-bowel transit (p < 0.001) and in more obtuse anorectal angles at rest (p = 0.007). In addition, sampling events were observed more commonly (p = 0.008) postoperatively. Preoperatively, incontinence was present in 13 patients (seven LAP and six OPEN) and persisted in four of them after rectopexy (two LAP and two OPEN). CONCLUSIONS: Resection rectopexy for rectal prolapse can be performed safely via the laparoscopic route. Recovery is uneventful and of shorter duration after the laparoscopic than after the open approach. Similarly satisfactory functional results are obtained with both procedures.

Aged↗
PubMed2006

Dynamic pelvic three-dimensional computed tomography for investigation of pelvic abnormalities in patients with rectocele and rectal prolapse.

BACKGROUND: Dynamic three-dimensional computed tomography (D-3DCT: high-speed helical scanning during defecation) was used for morphological evaluation of intrapelvic structures in patients with rectal prolapse and rectocele. METHODS: Twenty-five patients with rectal prolapse or rectocele diagnosed by conventional defecography (CD) or clinical findings were additionally investigated with D-3DCT. D-3DCT images were acquired using a multislice CT system with a 16-row detector during simulated defecation. Helical scanning was performed with a slice thickness of 1 mm, a helical pitch of 15 s/rotation, and a table movement speed of 35 mm/s. The contrast medium, 100 ml of iopamidol (370 mg/ml), was injected at a rate of 2.5 ml/s to enhance contrast with other structures, and scan start was triggered by using a function for automatically determining the optimal scan timing. RESULTS: Among the eight patients with rectocele, additional intrapelvic disorders were diagnosed in five (enterocele, 4; cystocele, 1; and uterine prolapse, 1) with D-3DCT. In the 17 patients with rectal prolapse, concomitant intrapelvic disorders were found in six (intussusception, 3; cystocele, 2; uterine prolapse, 2; rectocele, 1; and vaginal prolapse, 1). CONCLUSIONS: D-3DCT can be a useful diagnostic tool for investigation of pelvic pathology in patients with rectocele and rectal prolapse.

Adult↗
PubMed2005

Descending perineum syndrome: are abdominal hysterectomy and bowel habits linked?

PURPOSE: This retrospective study evaluates the effect of abdominal hysterectomy on patients affected by descending perineum syndrome. METHODS: Eighty-nine female patients affected by descending perineum syndrome and one group of 10 healthy women with normal bowel habits were studied retrospectively. Thirty-two descending perineum syndrome patients (Group 1) had received an abdominal hysterectomy for benign diseases, while 57 descending perineum syndrome patients (Group 2) had not undergone this surgery. All 99 subjects underwent clinical evaluation, computerized anorectal manometry, and defecography. RESULTS: Dyschezia was found predominantly in Group 2 subjects (P < 0.05). Fecal incontinence was significantly higher in Group 1 than in Group 2 (P < 0.05). The worst anal resting pressure was found in the incontinent Group 1 patients (P < 0.01). Rectoanal intussusception was a significant defecographic sign in Group 1 subjects (P < 0.05). CONCLUSIONS: Clinical evaluation and instrumental data suggested a possible link between fecal incontinence and abdominal hysterectomy in patients affected by descending perineum syndrome.

Aged↗
PubMed2000

[Surgical treatment of anterior rectoceles in women. The transanal approach].

Anterior rectocele is a herniation of the anterior rectal wall into the vagina, which may be either isolated or associated with other pelvic floor disorders. Rectocele could result in outlet obstruction with dyschezia, manual extraction of faeces and/or false incontinence. Rectocele is diagnosed clinically, and can be confirmed by defecography. Other tests may demonstrate associated causes of constipation. Symptomatic rectoceles can be treated via a transrectal route, with two or three layers of plication of the rectal wall and excision of the redundant mucosal flap. The results of transrectal repair are good: short hospital stay, no mortality, morbidity less than 5%, good short- and mid-term results in approximately 80% of cases. Selection criteria in favour of the transrectal approach have not been clearly identified.

Anal Canal↗
PubMed2006

[Descending perineum in women].

Physiopathological and clinical interpretation of the descending perineum as described by A. Parks in 1970 remains difficult. This review is based on the literature between 1966 and 2004. The observed symptoms are more often due to associated lesions. The descending perineum on X-ray is not always symptomatic. Colpocystography shows the descent of the perineum and pelvic disorders from the anterior and middle parts of the perineum whereas defecography seems to provide a better diagnosis of dyschesia due to posterior damage (such as rectocele or endo-anal intussusception). The first step of treatment is reeducation and medical treatment because there is no consensus for surgical therapy. Soft sacrocolpopexy by the abdominal approach with three meshes, one under the bladder, one in front of and one behind the rectum can be proposed for complete descending perineum. Transanal rectal resection by staple could be useful when the descending perineum is only associated with a rectocele and/or an intra-anal intussusception.

Defecation↗
PubMedDate not supplied

Functional results after laparoscopic rectopexy for rectal prolapse.

We investigated the functional results after laparoscopic rectopexy for rectal prolapse in 29 patients at least 12 months postoperatively. Twenty patients were evaluated completely pre- and postoperatively (median 22 months postoperatively, range 12 to 54 months). Six patients were interviewed by telephone, two patients were lost to follow-up, and one patient died of causes unrelated to rectal prolapse. Patients underwent a proctologic examination, anoscopy, rigid sigmoidoscopy, fluoroscopic defecography, and anorectal manometry pre- and postoperatively, and an additional standardized interview postoperatively. Anorectal manometry showed a significant increase in maximum anal resting and squeeze pressures postoperatively (resting pressure 72 +/- 8 vs. 95 +/- 13 mm Hg, pre- vs. postoperatively; P = 0.046; squeeze pressure 105 +/- 17 vs. 142 +/- 19 mm Hg, pre- vs. postoperatively; P = 0.035), and continence improved postoperatively (Wexner incontinence score 6.0 +/- 1.0 vs. 3.9 +/- 0.8 pre- vs. postoperatively, P = 0.02). Twenty (77%) of 26 patients were satisfied with the operative result, but functional morbidity was observed in four patients, with two patients complaining of severe evacuation problems. Rectal prolapse recurred in one patient 42 months postoperatively (recurrence rate 1 [3.8%] of 26 patients). Functional results were very similar to those obtained after open rectopexy, with symptoms of prolapse and incontinence improved in the great majority of patients.

Adult↗
PubMed2002

[New physiological, diagnostic and therapeutic concepts in the management of rectoceles in women].

Anterior rectocele is not only a herniation of the anterior rectal wall into the vagina, but rather a complex anatomical and functional abnormality which may be isolated or associated with other pelvic floor disorders. It could result in rectal obstruction with dyschezia, manual extraction of feces, and fecal or gas incontinence. The purpose of this review is to describe and to assess the most useful methods for the diagnosis and for the treatment of the rectocele. Data from physical examination may be improved by defecography. Surgery remains the main treatment: several surgical ways (perineal, anal, abdominal, laparoscopic) are described. Analysis of the anatomical and functional results allows to assess these techniques and to determine the best therapeutic option.

Defecation↗
PubMed2003

Obstructed defecation.

BACKGROUND: In the last decade our understanding of pelvic floor function and dysfunction has improved significantly. A more rational diagnostic and therapeutic approach is now possible for the group of patients with constipation due to obstructed defecation (OD). METHODS: The review is based on a literature search using the PubMed database focusing mainly on recent literature addressing the subject. RESULTS: Obstructed defecation occurs in about 7% of the adult population. Different pathophysiological mechanisms, either functional or anatomical, eventually lead to OD. Different tests (defecography, balloon evacuation test, manometry, electromyography, colonic transit time measurementmanometry) play an important role to quantify the problem. These tests are not without problems as abnormal results are also found in asymptomatic controls. Also, there is poor agreement between different tests and a poor correlation with symptomatology. Thus, for most syndromes conservative treatment including biofeedback is appropriate. Surgery can yield excellent results in selected cases. CONCLUSION: Validation of scoring systems and quantitative tests is still needed. More uniform and strict criteria for anismus should be applied to make therapeutic approaches comparable. Appropriate selection of patients for surgery is the key to success.

Biofeedback, Psychology↗
PubMed1997

Dynamic rectal examination: its significant clinical value.

The aim of the present study was to carry out a proper correlation between patients' clinical symptoms and the radiological findings obtained by dynamic rectal examination (DRE). At DRE, the small bowel and in females the vagina are routinely opacified in addition to defecography. A prospective study of 248 consecutive patients (193 women and 55 men, ratio 3.5:1) and 14 control subjects was conducted. The parameters assessed included the anorectal angle, the position of the anorectal junction, and the total movement of the pelvic floor during squeezing and defecation. Anatomical changes as rectoceles, enteroceles and intussusceptions were also observed. Based on the findings, the following conclusions can be drawn. There is no indication for measurement of the central or posterior anorectal angle. There is no indication for measurement of the perineal ascent, perineal descent, and anorectal junction level. Anterior rectoceles occur very frequently in females, and are only of clinical relevance if the patients need digital vaginal support to facilitate defecation. DRE is a sensitive method for diagnosing enteroceles and intussusceptions.

Anal Canal↗
PubMed2000

Pelvic floor study in patients with obstructive defecation: influence of biofeedback.

The aim of this study was to evaluate the pathophysiologic abnormalities in patients with obstructive defecation or dyssynergia and to assess the role of biofeedback treatment. Three groups were studied. Group A had 24 patients with obstructive defecation; B, 25 patients with constipation; and C, 22 healthy volunteers. Rectosigmoid segmental transit time of group A was 28.5 hours (SD +/- 13.4); B, 17.2 hours (SD +/- 11.5); and C, 8.5 hours (SD +/- 6.3) (p < 0.05). There was no statistical difference in resting and squeezing anal pressure among the three groups. Anorectal angle at rest revealed no difference among the three groups. At strain, a statistically significant difference between groups A and C (p < 0.05) and a marginal difference between groups A and B was noted. Rectocele of the anterior rectal wall was present at strain in 17/24 patients of group A and 7/22 patients of group C (p < 0.05). Electromyography during strain revealed abnormal contractions of puborectalis muscle and external anal sphincter, in 13 and 14 patients of group A, respectively, which differed from that observed in groups B and C (p < 0.001). Biofeedback treatment was applied with good results in 7 of 11 patients of group A. At six months, constipation relapsed in only one of treated patients. Patients suffering from obstructive defecation seem to have slower rectosigmoid transit time than the others. Defecography shows smaller anorectal angle at strain and rectocele of the anterior rectal wall more often. Abnormal pelvic floor contraction at strain is often noted in anal electromyography. Some of these patients seem to respond favorably to biofeedback treatment.

Adult↗
PubMed2003

Magnetic resonance imaging of anatomic and dynamic defects of the pelvic floor in defecatory disorders.

OBJECTIVE: Endoanal ultrasound identifies anal sphincter anatomy, and evacuation proctography visualizes pelvic floor motion during simulated defecation. These complementary techniques can evaluate obstructed defecation and fecal incontinence. Our aim was to develop a single, nonionizing, minimally invasive modality to image global pelvic floor anatomy and motion. METHODS: We studied six patients with fecal incontinence and seven patients with obstructed defecation. The anal sphincters were imaged with an endoanal magnetic resonance imaging (MRI) coil and endoanal ultrasound (five patients). MR fluoroscopy acquired images every 1.4-2 s, using a modified real-time, T2-weighted, single-shot, fast-spin echo sequence, recording motion as patients squeezed pelvic floor muscles and expelled ultrasound gel; no contrast was added to other pelvic organs. Six patients also had scintigraphic defecography. RESULTS: Endoanal ultrasound and MRI were comparable for imaging defects of the internal and external sphincters. Only MRI revealed puborectalis and/or external sphincter atrophy; four of these patients had fecal incontinence. MR fluoroscopy recorded pelvic floor contraction during squeeze and recorded relaxation during simulated defecation. Corresponding comparisons for angle change and perineal descent during defecation were not significant; only MRI, but not scintigraphy, identified excessive perineal descent in two patients. CONCLUSIONS: Pelvic MRI is a promising single, comprehensive, nonradioactive modality to measure structural and functional pelvic floor disturbances in defecatory disorders. This method may provide insights into mechanisms of normal and disordered pelvic floor function in health and disease.

Adolescent↗
PubMed2006

Pathophysiology and role of biofeedback therapy in solitary rectal ulcer syndrome.

BACKGROUND: Solitary rectal ulcer syndrome (SRUS) is a behavioral disorder whose pathophysiology is incompletely understood. Likewise, its treatment, particularly the role of biofeedback therapy (BT) is unclear. AIM: To evaluate anorectal function and morphology and to assess efficacy of BT. METHODS: Eleven patients (8f) with refractory SRUS underwent symptom assessments, anorectal manometry, defecography, balloon expulsion test, and sigmoidoscopy. Physiological tests were also performed in 15 (11f) healthy controls. Subsequently, SRUS patients underwent biofeedback treatment. Symptoms and manometry were reassessed. RESULTS: Nine (82%) patients exhibited dyssynergia ( p < 0.001). Rectal sensory thresholds were decreased (p < 0.04). After biofeedback, straining effort and stool frequency decreased ( p < 0.05), and bowel satisfaction score (VAS) improved ( p < 0.001). Digital maneuvers were discontinued by all five patients and bleeding stopped in 56%. The defecation index increased ( p < 0.05), dyssynergia normalized, and balloon expulsion time decreased ( p < 0.05). There was complete healing in 4 (36%), > or =50% healing in 2 (18%), and <50% healing in 4 (36%) patients. CONCLUSIONS: SRUS associated with excessive straining, digital disimpaction, rectal hypersensitivity, dyssynergic defecation, and prolonged evacuation. BT may improve symptoms and anorectal function and facilitate healing.

Adolescent↗
PubMed2001

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

OBJECTIVE: The aim of this study was to provide measurements for the defecographic diagnosis of rectal intussusception and rectal prolapse. MATERIALS AND METHODS: Four hundred thirty-seven consecutive patients with defecation and micturition disorders and gynecologic complaints were studied by means of defecography (120 patients), colpodefecography (17 patients), or cystocolpodefecography (300 patients). As a control group, 43 asymptomatic subjects underwent defecographic examination. RESULTS: Thirty-five patients were found to have rectal intussusception and 18, to have rectal prolapse. Anterior and posterior rectal wall folding thickness, intussuscipiens diameter, intussusceptum lumen diameter, and the ratio between the intussuscipiens diameter and the intussusceptum lumen diameter were measured in all patients. The findings were compared with those obtained in 13 of 43 asymptomatic subjects with rectal outline changes mimicking intussusception. Rectal folding thickness and the ratio between the intussuscipiens diameter and the intussusceptum lumen diameter were significantly greater in subjects with rectal intussusception and rectal prolapse than in asymptomatic subjects with rectal mucosa folding. CONCLUSION: Our findings suggest that dynamic evacuation radiology contributes to making a differential diagnosis between rectal intussusception and mucosal folds in the rectum.

Case-Control Studies↗
PubMed1997

Quality of life in patients with different types of functional constipation.

BACKGROUND: Little information is available about the health-related quality of life (QoL) in patients with different types of chronic constipation. METHODS: We used two self-administered questionnaires, the Psychological General Well-Being (PGWB) index and the Gastrointestinal Symptom Rating Scale (GSRS) to assess QoL and gastrointestinal symptoms in 102 consecutive patients with chronic constipation. The type of constipation was determined from transit time, electrophysiologic investigation of sphincter function, anorectal manometry, and defecography. RESULTS: Overall, our patients with constipation reported low scores for general well-being (mean score, 85.5, compared with 102.9 in a healthy population). Patients with normal-transit constipation (n = 49) reported considerably lower scores in the PGWB than those with slow-transit constipation (n = 35). The symptoms increased frequency of defecation, loose stools, and urgent need for defecation were commoner in normal-transit constipation, which indicates that this group may have a relation to the irritable bowel syndrome. The overall PGWB index was strongly correlated with the total GSRS (P < 0.001). CONCLUSIONS: The general well-being of patients with chronic constipation is lower than that of a comparable normal population. Symptom severity correlates negatively with perceived quality of life.

Adolescent↗
PubMed2005

Dynamic MR imaging of outlet obstruction.

The outlet obstruction syndrome encompasses all pelvic floor abnormalities which are responsible for an incomplete evacuation of fecal contents from the rectum. It has been estimated that outlet obstruction may be observed in half of constipated patients. A detailed clinical examination still represents the cornerstone of the diagnosis of these patients. However, there is general agreement that a reliable evaluation of the different pelvic floor abnormalities and the treatment decision highly depend on the imaging assessment. Traditionally, conventional defecography has played an important role in the radiological assessment of these patients but the technique is limited by its projectional nature and its inability to detect soft-tissue structures. Dynamic pelvic MR imaging using either closed-configuration or open-configuration MR systems is a rapidly evolving technique which has been gaining increased interest over the last years. The free selection of imaging planes, the good temporal resolution, and the excellent soft-tissue contrast have transformed this method into the preferred imaging modality in the evaluation of patients with pelvic floor dysfunction including rectocele, enterocele, internal rectal prolapse, and anismus.

Constipation↗
PubMed1997

[Video laparoscopic surgery and rectal prolapse. Our experience in rectopexy].

BACKGROUND: Laparoscopy is gaining an important role in the treatment of benign colorectal disorders. The aim of this study is the evaluation of clinical and functional results in 4 patients submitted to a laparoscopy rectopexy according to Wells. METHODS: Four females (22-76, mean 53.7 years) affected from a total rectal prolapse with fecal incontinence underwent this procedure from 1993 through 1995. Six months after surgery, at the end of a rehabilitation program consisting of kinesitherapy, bio-feedback and electrostimulations, all patients have been re-evaluated by means of a clinical exam, anorectal manometry, defecography. RESULTS AND CONCLUSIONS: Preliminary results seem satisfactory and may allow to prefer this approach instead of the traditional open one.

Adult↗
PubMed1998

[Adult fecal incontinence due to anal sphincter lesions: which preoperative preparations? Which surgical solutions?].

Management of fecal incontinence due to anal sphincter lesions involves a good preoperative evaluation. This tends to confirm the incontinence, to search its mechanism, and to classify it according to the type of sphincter lesion owing to manometry, ultrasonography, and defecography. The surgical option is discussed after failure of medical treatment and biofeedback. The aim of surgery is to restore the incontinence and to maintain the exemption function. The surgical procedures include the sphincter repairs, the sphincter substitution, or even colostomy. Among the procedures of sphincter repairs, the direct repair is performed for obstetrical ruptures or postsurgical lesions of the anal sphincter, and the pelvic floor repairs are performed for fecal incontinence with intact but poorly functioning sphincter. Failures of these conservative methods lead the surgeons to develop new techniques for anal sphincter substitution. Dynamic graciloplasty and artificial sphincter (both under evaluation) constitute currently the promising alternatives to colostomy.

Adult↗