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PubMed2006

Innervation of the rectovaginal wall in patients with rectocele compared to healthy controls.

AIMS: To evaluate if pelvic floor innervation differed in patients with rectocele compared to control subjects and to assess if nerve fiber density of the rectovaginal wall correlated to the clinical presentation of rectocele. METHODS: Biopsies from 24 female patients with posterior vaginal wall prolapse stage II (ICS-classification) and rectocele verified at defecography were compared to specimens from age and parity-matched control subjects without posterior vaginal wall prolapse. Nerve fiber density was measured using protein gene product (PGP-9.5) antibodies at immunohistochemistry. Anorectal symptoms were recorded using bowel and anorectal function questionnaires. RESULTS: The two groups were comparable in age and parity. Mean nerve fiber immunofluorescence intensity was 150.3 +/- 12.5 SD in the patient group compared to 139.3 +/- 8.5 SD in the control group (P < 0.01). Symptoms of anorectal dysfunction were more common in the patient group compared to control subjects (P < 0.01) but there was no difference in anal continence. At logistic regression analysis, nerve fiber immunofluorescence intensity showed no significant correlation to age, menopausal age, parity, body mass index (BMI), prolapse quantification, or any specific self-reported anorectal symptom. Increased nerve fiber immunofluorescence intensity was correlated to increased perineal descent (OR 1.3, 95% CI 1.1-2.1) although not to the size of the rectocele (OR 0.5, 95% CI 0.9-1.2). CONCLUSIONS: Our results show that rectocele may be associated with increased rectovaginal innervation, suggestive of reinnervation of the rectovaginal wall. Nerve fiber density correlated poorly with findings at clinical and radiological examination. Neurochemical characterization of the rectovaginal wall may provide further understanding of the pathogenesis of rectocele.

Aged↗
PubMed1992

Defecatory disorders, anorectal and pelvic floor dysfunction: a polygamy? Radiologic and manometric studies in 41 patients.

A consecutive series of 41 patients with defecatory disorders was prospectively studied by anal manometry and evacuation proctography to determine the relationship between abnormalities and symptoms. The patients (29 female, 12 male, aged 41 +/- 2.3 years) all complained of difficulty in evacuation. All had normal colonoscopy and biochemistry. There was no evidence of megacolon or megarectum, and no symptoms had been previously treated by pelvic floor surgery. All subjects completed detailed questionnaires related to gastrointestinal symptoms with special reference to excessive straining and discomfort, digital manipulations during defecation, a sense of pelvic heaviness and incomplete evacuation. Each patient underwent clinical examination, anal manometry and defecography during a single outpatient visit. Rectocele (16 patients) was significantly associated with vaginal digitation, lower stool frequency, delayed rectal emptying and decreased rectal sensation to distension. Increased anal pressure on straining (14 patients) was also related to a poor rectal emptying in 13 patients. Neither perineal descent (24 patients) nor external rectal prolapse (12 patients) was related to objective obstruction. Nevertheless there was an association with pelvic heaviness and lower anal manometric recordings. Five among 16 patients with rectocele had manometric anismus. Forty percent of patients with intussusception also had a paradoxical sphincter response during defaecation. Furthermore, associated abnormalities were extremely common (34 of 41 patients), accurate interpretation of which was necessary for planning effective therapy.

Adult↗
PubMed1996

Anterior rectocele and anorectal dysfunction.

The two types of anterior rectocele, "distension" of Type 1 rectocele (T1R) and "displacement" or Type 2 rectocele (T2R), have different anatomical, clinical and therapeutic profiles. The aim of this study was to assess anorectal function in patients with distension or displacement rectocele. Three groups of female patients and one group of healthy female subjects were studied. Both the 10 Group 1 subjects, who had been diagnosed as having T1R, and 10 Group 2 women who had been diagnosed as having T2R, were symptomatic for digital evacuation of the rectum. The 10 Group 3 females had complained of sever idiopathic constipation but had no defecatory disorders. The control group was made up to 10 healthy volunteers. All patients and controls underwent clinical evaluation, colonic transit time (CTT), computerized anorectal manometry (CAM), and defecography. Bowel movements and clinical evaluation were similar for both rectocele groups. In Group 1, CAM detected significantly higher anal pressure (P < 0.05) and more impaired rectoanal inhibitory reflex (RAIR) (P < 0.01) in comparison to the other patients and controls. In Group 2, the lowest anal pressure (P < 0.001) was noted but RAIR was normal. Defecographic results, at rest and during evacuation, showed a significantly (P < 0.001) higher anorectal angle and a more abnormal pelvic floor descent in Group 2 than in the other study groups and controls. Therefore, peculiar anorectal function was present in patients with anterior rectocele. A pelvic floor dyssynergia was noted in the distension rectocele group, while a fall of the pelvic floor was noted in the displacement rectocele group.

Adult↗
PubMed1987

Persisting incontinence after postanal repair treated by anterior perineoplasty.

Eight patients who failed to achieve continence after postanal repair for idiopathic incontinence were treated by anterior perineoplasty. Six gained satisfactory continence. Failure of the original postanal repair was probably because the anterior part of the pelvic floor had not been sufficiently supported as indicated by defecography pre- and postoperatively. Anterior perineoplasty corrected this defect.

Aged↗
PubMed1993

Colpocystodefecography.

PURPOSE: To assess, in one single procedure, a complete study of the female pelvis, including the Douglas pouch. METHODS: Colpocystodefecography (CCD) combines vaginal opacification, voiding cystography, and defecography. Three hundred examinations are reviewed. RESULTS: Thanks to the simultaneous visualization of the pelvic structures, CCD proved to be more useful than clinical evaluation to diagnose prolapses and particularly Douglas pouch hernias (enteroceles), the clinical diagnosis of which was missed in 93 of 111 cases. Moreover, in addition to morphologic and functional information, CCD brings about a new insight in the study of pelvic organs reciprocal influences, should they be positive (supporting function) or negative (external compression). Finally, significative pelvic surgery and particularly hysterectomy enhances greatly the risk of enteroceles. CONCLUSION: CCD is helpful in the preoperative staging, especially in the selection of the surgical procedure that will least likely predispose to possible late postoperative complications such as vaginal prolapses or enteroceles.

Adult↗
PubMed1993

Defecographic findings in patients with anal incontinence and constipation and their relation to rectal emptying.

PURPOSE: The aim of this study was to examine defecographic findings in patients with anal incontinence and constipation and to compare these findings with rectal emptying. METHODS: One hundred seventy-five preoperative defecographies documented on videotape in patients with either anal incontinence or constipation were retrospectively reviewed. The examinations were evaluated with respect to anatomic abnormalities of the rectum or anal canal. The results were compared with a semi-quantitative assessment of rectal emptying as it appeared on the video sequence after one minute of strain. RESULTS: Anatomic abnormalities were found equally in incontinent and constipated patients, except for failure to open the anal canal, which was found only in constipated patients. Rectal intussusception was the most frequent finding. Abnormal defecograms were found in both sexes. Enteroceles, sigmoidoceles, and large rectoceles were found only in women. The presence of intussusception, lacking relaxation of the puborectalis muscle, and rectocele did not correlate with poor rectal emptying. Poor rectal emptying was also found in 19 of 58 patients with normal defecograms. CONCLUSIONS: Anatomic abnormalities of the rectum may be demonstrated independently of the clinical symptoms and are not always correlated to impaired rectal emptying. Since they may also be found in healthy controls, surgical correction of these abnormalities should be considered only with great caution.

Adult↗
PubMed1994

Continent perineal colostomy by transposition of gracilis muscles. Technical remarks and results in 14 cases.

UNLABELLED: We herein present a study conducted on 14 patients presenting cancer of the lower rectum or of the anal canal (10 adenocarcinomas and 4 squamous-cell carcinomas) and submitted to the Miles abdominal perineal resection in which a new perineal sphincter was constructed. PURPOSE: The aim of this study was to evaluate the efficacy of this new perineal sphincter constructed by transposing the gracilis muscles around an orthotopic colostomy in the attempt to avoid a permanent abdominal colostomy. METHODS: In all cases both gracilis muscles were employed. The right one was placed along the posterior wall of the pelvis and fixed to the contralateral ischiatic tuberosity, creating a sling comparable to the levator ani muscles. The left gracilis was passed around the colon and attached to the ipsilateral or contralateral tuberosity according to its length, reconstructing a muscular ring. The entire procedure was performed in one step in nine cases and in more steps in the remaining five. RESULTS: Of the 14 operated patients, 2 died of vascular disease and 1 developed necrosis of the colonic stump which required reconversion to an abdominal colostomy. Of the remaining 11 patients available for long-term evaluations, 8 showed adequate stool control. The remaining three manifested an incomplete level of continence. During the three-year follow-up period, all patients were evaluated by clinical examination, defecography, endoluminal ultrasonography, nuclear magnetic resonance, CT scan, and endoluminal manometry. CONCLUSION: This neosphincter realizes an elastic stenosis responsible for an efficient level of continence. Best results are observed in the young and educated patients submitted to surgery in two steps. Contraindications to this surgery seem to be advanced cancer, old age, and obesity.

Adenocarcinoma↗
PubMed1992

Association between rectocele and paradoxical sphincter response.

Rectocele as well as paradoxical sphincter reaction may lead to rectal emptying difficulties and outlet obstruction. Forty-one patients with emptying disturbances and rectocele were investigated with defecography, anorectal manometry, colon transit time, and electromyography. Twenty-nine patients (71 percent) had concomitant paradoxical sphincter reaction, and 13 of these also had increased colon transit time. The functional results after surgical treatment of rectocele are not always satisfactory, probably because patients often have several causes for their emptying disturbances. It is emphasized that careful preoperative investigations are important before surgical treatment of rectocele in patients with emptying difficulties.

Adult↗
PubMed1991

Anorectal physiology testing. A survey of availability and use.

Survey forms were sent to all members of the Coloproctology Section of the Royal Society of Medicine and the American Society of Colon and Rectal Surgeons to obtain their opinions of the availability, actual use, and perceived helpfulness of different methods for the evaluation of the physiology of the colon and rectum. Responses revealed a similarity in age and practice patterns in both groups. Of the 19 methods surveyed, greater than 90 percent of respondents in both groups rely on three traditional methods of patient evaluation: patient history, digital examination, and sigmoidoscopy. Four other methods have gained acceptance by the majority of respondents in both groups: colon transit studies, defecography, perfused-catheter manometry, and rectal compliance. The three methods ranked lowest in availability, actual use, and helpfulness by both groups were single-fiber electromyography, use of a perineometer, and evoked potential studies. Our study provides a baseline for future surveys on the investigative efforts of physicians studying the physiology of the colon, rectum, and anus.

Anal Canal↗
PubMed1991

Manometric and radiologic investigations and biofeedback treatment of chronic idiopathic anal pain.

In 12 patients suffering from chronic idiopathic anal pain, the rectosphincteric function was studied using manometric and x-ray techniques. The results of manometric investigations were compared with those obtained in 12 healthy volunteers. In all patients, the resting pressure in the anal canal was significantly higher than in control subjects. In 10 patients, defecography revealed abnormalities of the pelvic muscles. We treated the patients by using biofeedback techniques, consisting of voluntary modifications of the state of contraction of the external sphincter. In all cases, pain disappeared after a mean of eight biofeedback training sessions. When noxious manifestations had disappeared, manometry showed a significant decrease in the anal canal resting pressure. Our results indicate 1) that chronic idiopathic anal pain is associated with abnormal anorectal manometric profiles, probably resulting from a dysfunctioning of the striated external anal sphincter, and 2) that biofeedback training is an effective treatment for chronic idiopathic anal pain.

Adult↗
PubMed1997

Chronic constipation--is the work-up worth the cost?

BACKGROUND: Chronic constipation can be a disabling condition that may require colectomy. Evaluation has been included as a way to select appropriate patients for colectomy and may also be extensive, unrevealing, and costly. AIMS: This study was undertaken to determine the cost and use of evaluation and outcome of patients with chronic constipation. METHODS: Patients with chronic constipation were reviewed for severity of symptoms, diagnostic studies performed, treatment, and outcome. The costs of the diagnostic studies were determined at our institution. Fifty-one patients were identified with chronic constipation; all were referred by other physicians. Mean age was 54 (range, 21-81) years; 59 percent were females. Average number of bowel movements per week was two (range, 0-4), and average duration of symptoms was five years (range, 1-20). Forty-three of 51 (84 percent) colonoscopies or barium enemas were normal. Thirteen of 51 (25 percent) colonic transit studies were abnormal. Twenty-six of 51 (51 percent) patients underwent defecography; 12 (46 percent) were abnormal. Thirty-seven of 51 (74 percent) underwent anal manometry; 5 (14 percent) were abnormal. One of 18 (6 percent) rectal biopsies demonstrated Hirschsprung's disease. Overall, 8 patients (16 percent) were diagnosed with outlet obstruction, 12 (24 percent) with colonic inertia, and 31 (61 percent) with constipation of unclear etiology. Overall mean cost of diagnosis was $2,752 (range, $1,150-$4,792). Fiber, cathartics, or biofeedback therapy was successful in 33 of 51 (65 percent) patients. Among the remaining 18 patients, 12 underwent surgery, of which 10 were successful. The remaining eight patients were constipated, despite treatment. CONCLUSION: A cost of $140,369 was expended on extensive diagnostic tests, from which 12 of 51 (23 percent) patients benefited. Exhaustive diagnostic evaluation of constipation is costly, and its benefits are unclear.

Adult↗
PubMed1993

Functional intraperineal pouch of rectal wall (posterior rectocele).

We have identified 18 cases of functional pouch of the posterior rectal wall visualized by defecography. In the absence of previous evidence in the literature, we named this anomaly "posterior rectocele" and studied it from the clinical, radiologic, and endoscopic points of view.

Adult↗
PubMed1997

Symptoms in chronic constipation.

OBJECTIVES: This study was designed to evaluate whether detailed symptom analysis would help to identify pathophysiologic subgroups in chronic constipation. METHODS: In 190 patients with chronic constipation (age, 53 (range, 18-88) years; 85 percent of whom were women), symptom evaluation, transit time measurement (radiopaque markers), and functional rectoanal evaluation (proctoscopy, anorectal manometry, defecography) were performed. Patients were classified on the basis of objective data from all tests in four different groups ("disordered defecation," "slow gastrointestinal transit," "disordered defecation combined with slow-transit stool," and "no pathologic finding"). RESULTS: In 59 percent of patients, disordered defecation was found, and 27 percent had slow-transit stool. In 6 percent of patients, a combination of both was found; in only 8 percent of patients, there were no pathologic findings. Straining was reported by the vast majority in all groups (82-94 percent). Infrequent bowel movements and abdominal bloating were more common in slow-transit stool (87 and 82 percent vs. 69 and 55 percent, respectively; both P < 0.01). Feeling of incomplete evacuation was more common in disordered defecation (84 vs. 46 percent; P < 0.0001). However, specificity of these symptoms was discouraging (for slow-transit stool: infrequent bowel movements had a sensitivity of 87 percent and a specificity of 32 percent and abdominal bloating had a sensitivity of 82 percent and specificity of 45 percent; for disordered defecation: feeling of incomplete evacuation had a sensitivity of 84 percent and a specificity of 54 percent). Only the sense of obstruction and digital maneuvers were acceptably specific (79 and 85 percent, respectively) for disordered defecation, but sensitivity was low. CONCLUSIONS: Definition of chronic constipation by infrequent bowel movements alone is of little value; the symptom "necessity to strain" is much better suited (94 percent sensitivity). Specificity of infrequent bowel movements for slow-transit stool was discouraging. Sense of obstruction and digital manipulation for evacuation are relatively specific for disordered defecation but insensitive. Therefore, symptoms of chronically constipated patients are not well suited to differentiate between the pathophysiologic subgroups suffering chronic constipation.

Adolescent↗
PubMed1990

Streamlining the management of defecation disorders.

Obstinate constipation is a frequent but elusive gastrointestinal symptom. Increased understanding of defecation physiology and recent availability of simple, ready-to-use tools have increased specificity of both diagnosis and treatment. This patient series includes over 700 severely constipated patients with over 70 percent overall therapeutic success. Cinedefecography, pelvic floor electromyography, and determination of rectoanal inhibitory reflex were performed with simple and readily available equipment to document outlet anatomy and dynamics. Colonic transit time was examined in patients whose defecography and electromyography results were nondiagnostic and/or whose response to medical management was suboptimal, using a commercially available marker capsule, followed by abdominal x-rays. Retention of markers throughout the colon suggested colonic hypomotility or "inertia"; rectosigmoid retention confirmed functional outlet obstruction. With careful history, physical examination, and exclusion of organic causes, orderly application of readily available techniques can afford rapid, objective, and anatomically specific evidence upon which treatment of disordered defecation may be based.

Cineradiography↗
PubMed1990

Slow transit of the colon associated with severe constipation after the Ripstein operation. A clinical and physiologic study.

Eighteen patients with severe constipation after undergoing the Ripstein operation for rectal prolapse (n = 11) or internal rectal procidentia (n = 7) were studied with defecography, anorectal manometry, electromyography of the external anal sphincter and the puborectalis muscle, colonic transit time, and blood tests. Thirteen patients had slow-transit constipation. None showed a completely normal pattern in the parameters studied. The authors emphasize the importance of careful preoperative investigation to identify the patients who have associated colorectal disturbances together with their rectal prolapse or internal rectal procidentia.

Adult↗
PubMed1990

Application of the colorectal laboratory in diagnosis and treatment of functional constipation.

Defecography, pelvic floor electromyography, and segmental colonic transit times were performed in 74 patients with functional constipation. Signs of functional outlet obstruction occurred in 74 percent. Transit times were normal in 33 percent. Measurement of colonic transit time in patients with disordered evacuation studies is useless from a clinical point of view, because abnormal segmental transit time is the result of outlet obstruction in most cases and will return to normal after adequate treatment. Only when evacuation studies are normal, or have become normal after treatment and constipation persists, are segmental transit studies indicated because they may demonstrate primary slow transit constipation. Primary slow transit constipation probably is caused by impaired motility of the whole gastrointestinal tract. As small-bowel transit time increases, defecation frequency decreases, laxatives are taken again, and abdominal pain persists. Surgery should be performed with restraint.

Adult↗
PubMed1992

Outpatient protocol for biofeedback therapy of pelvic floor outlet obstruction.

Pelvic floor outlet obstruction is a rare cause of severe constipation. Anal myectomy, subtotal colectomy, and medical therapy have limited success. The purpose of this study was to develop a short outpatient treatment using biofeedback techniques. Nine patients with severe constipation and straining resulting from pelvic floor outlet obstruction underwent complete investigation of the pelvic floor musculature and anal sphincter mechanism. Patients were unable to expel a 60-cc rectal balloon and had nonrelaxing puborectalis on defecography. The treatment protocol utilized anal surface electromyography to document improper straining and retrain pelvic floor muscles to relax during defecation. Sensory retraining with a rectal balloon, behavioral relaxation techniques, and defecation of simulated stool using a 120-cc Metamucil (Procter & Gamble, Cincinnati, OH) slurry in the rectum allowed re-establishment of normal defecation in all nine patients. Repeat training was required in three patients during follow-up. Treatment of pelvic floor outlet obstruction with outpatient retraining techniques is possible.

Adult↗