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PubMed2002

[Chronic idiopathic anal pain syndrome].

INTRODUCTION: The study was undertaken to analyse whether intra-anal ultrasound examination, anorectal physiological evaluation, and histopathological examination of patients suffering from chronic idiopathic anal pain presented any common features and to analyse the results of various treatments. MATERIAL AND METHODS: Eighteen patients who met the criteria for chronic idiopathic anal pain were studied. Treatment included 0.2% glyceryl nitrate ointment, ultrasound guided injection of botulinum toxin in the intrasphincteric space, analgesics, and colostomy. RESULTS: Anal physiological examinations were normal in all but one patient. Intra-anal ultrasonography demonstrated abnormalities in 12 patients. Defecography showed in one patient a small distal invagination but was otherwise normal. Glyceryl nitrate ointment had an effect in one of four patients, and botulinum toxin in four of nine. Two patients needed a colostomy for definitive pain relief, and in 12 of the 18 patients the final treatment was analgesics. DISCUSSION: The methods used in this study did not contribute to the understanding of the pathogenesis of chronic anal pain. The treatment is experimental, but injection of botulinum toxin may be tried on the hypothesis that dystonia in the anal sphincter may play a pathogenetic role.

Adult↗
PubMed2001

[Preliminary results of dynamic gracilloplasty in the treatment of fecal incontinence].

UNLABELLED: Transposition of the gracilis muscle and its continuous electrical stimulation became a widely accepted method for treatment of patients with severe fecal incontinence. This method introduced to clinical practice by Baeten, Williams and Cavina has also been applied in total anorectal reconstruction following abdominoperineal rectum resection due to rectal cancer. This paper describes our (limited so far) experience with dynamic gracilloplasty procedure in the treatment of fecal incontinence in six patients with injury of anal sphincters. Complete preoperative work up was based on the clinical symptoms of fecal incontinence evaluated in detail according to Jorge and Wexner Incontinence Scoring System and the clinicomanometric continence criteria according to Holscheider scale. Anorectal manometry, transanal endosono-graphy, defecography and barostat study were performed in each patient before and following surgery. Dynamic gracilloplasty procedure was performed according to the modified Baeten procedure--as a one stage procedure. Medtronic equipment (IPG Pulse Generator 3023) was applied for gracilis stimulation. Short term program of fast-to-slow muscle conversion was applied starting from the second week following surgery. Patients were prospectively evaluated after surgery in terms of clinical symptoms and anorectal physiology. Complete fecal continence was achieved in all patients during the first month following surgery. There were no serious postoperative complications. It was shown during anorectal manometry that dynamic gracilloplsty could increase the anal sphincter pressure up to the range of healthy subjects, thus to prevent fecal leakage. The overall clinical and manometic results confirm the feasibility of anal dynamic gracilloplasty to restore fecal continence in patients with complete lost of sphincter function due to its traumatic injury or atresia. This technique deserves wider application also in Poland, since our initial results are encouraging. CONCLUSION: According to our limited experience dynamic gracilloplasty proved safe and effective procedure for the treatment end-stage fecal incontinence. Complete preoperative diagnostic work-up is essential for proper patients selection and surgical procedure should be performed in a specialised surgical center.

Adult↗
PubMedDate not supplied

Anal incontinence: evaluation and biofeedback therapy.

Incontinence is a very stigmatizing symptom in our society. About 1% of the adult population is affected by fecal incontinence. In the evaluation anorectal manometry and defecography play a major role. Therapy often is still disappointing. In recent years simple retaining or biofeedback therapy have been reported to improve about 70% of incontinent patients. Within one year we treated 19 patients. Success was achieved in 69%. Biofeedback training, therefore, should be attempted prior to considering surgery.

Biofeedback, Psychology↗
PubMed2004

[Internal rectal invagination treated with rectopexy and sigmoid resection].

BACKGROUND: Internal rectal intussusception, usually occurring in women, causes constipation and incomplete evacuation of stool. MATERIALS AND METHODS: Twenty-one women and one man (median age 48) were operated with suture rectopexy and sigmoid resection. The patients were examined with anoscopy and defecography, and symptomatic outcome, patients' satisfaction and morbidity were evaluated. Outcome was based mainly on the validated KESS score for constipation. RESULTS: There was a significant reduction in all ten symptoms. Faecal incontinence improved in the two afflicted patients after operation. The number of patients with constipation was reduced from 20 to 8 (p < 0.01); none became constipated. Mean (95 % CI) colonic transit times in ten constipated patients was reduced from 5.3 (4.1-6.4) to 4.0 (2.6-5.4) days (p = 0.08); seven of these patients had a reduction of transit time as well as constipation score. INTERPRETATION: Rectopexy with sigmoid resection improved symptoms, including constipation and feeling of incomplete rectal emptying.

Adult↗
PubMedDate not supplied

[Stapled hemorrhoidopexy in the treatment of hemorroidal prolapse].

In the treatment of hemorroidal prolapse, stapled hemorrhoidopexy, according to the Longo's technique, represents an innovative and interesting procedure. The Authors consider own experience in the years 2001-2002, estimating preliminary results in the treatment of 50 patients affected by hemorrhoidal disease classified as III-IV grade, associated with mucosal prolapse, rectocystocele in 5 cases, anal fissures in 6 and hyperplastic polyp in 1. The patients were submitted to mucosal prolapsectomy with mechanical stapler (PPH 01-33 Ethicon), applying haemostatic stitch on suture line, apart from intraoperative bleeding, associated to closed anal sphincterotomy in 6 cases, and resection of anal hyperplasic polyp in 1. In 5 cases of rectocystocele a Burch's culposuspension was associated to a stapled transanal rectal resection (STARR). After 3 and 12 months the Authors performed ano-rectoscopy, anal manometry and defecography. Mean operative time was 45 minutes (range 20'-130') and mean hospital stay was 3 days (range 2-6 days). In the early postoperative course urinary ritention in 4 cases, treated with temporary catheterization in 3 and permanent for 72 hours in 1, was observed. Only 1 patient, was reoperated in day-surgery and with loco-regional anesthesia for residual fibrous hemorroid. Bleeding, severe pain, anal stenosis, impairment of continence were not observed. According to the Literature data, our experience confirm that mucoprolapsectomy represents an innovative, safe, simple and definitive operation in the treatment of hemorrhoids disease. In case of rectal prolapse associated to external fibrous hemorroids, a combined surgical treatment is requested in order to achieve better results.

Adult↗
PubMed2005

[Descending perineum in women].

The descending perineum syndrome, described in 1970 by Alan Parks, remains difficult to interpret clinically and pathophysiologically. A general review of descending perineum was conducted, based on review of the literature published between 1966 and 2004, and retrospective analysis of 1,023 colpocystograms. The symptoms observed are usually secondary to associated lesions. Radiological signs of descending perineum are not always associated with clinical symptoms. Colpocystogram shows perineal descent and associated disorders of anterior and middle pelvic tone, while defecography provides a better explanation for dyschezia which is generally due to an associated posterior disorder (rectocele with rectal intussusception). The management of descending perineum is based on medical treatment and retraining. No consensus has been reached concerning surgical management. Surgery is generally used to treat associated lesions. In the case of complete collapse of perineum, an abdominal approach with infravesical, prerectal and retrorectal tension-free tape to the sacrum could be useful, while transanal staple repair of the rectum could be proposed when descending perineum is associated with only rectal intussusception or rectocele.

Female↗
PubMed2005

[Long-term results of excision of anal fissure in combination with lateral subcutaneous sphincterotomy].

One hundred and seventeen patients with anal fissure underwent fissure excision in combination with lateral subcutaneous sphincterotomy. The mean follow-up after treatment was 4.3 years. All the patients were questioned by the phone. Thirty-six ones who had some symptoms were examined at outpatient department. The examination included physical examination, anorectal manometry, endorectal ultrasonography, irrigoscopy, defecography. Recurrences of anal fissure were revealed in 12 (10.2%) patients. The cause of recurrence was incomplete sphincterotomy. Different grade of anal incontinence was revealed in 23 patients: 2 of them had soiling, 12 -- incontinence of the flatus, 8 -- incontinence of liquid faeces, 1 -- incontinence of solid faeces. In 4 patients the cause of anal incontinence was excessive sphincter section during sphincterotomy, in 16 -- perineal descent syndrome, in 3 -- advanced age. It is concluded that it is necessary to modify surgical technique and to examine patients more carefully before surgery including anorectal manometry.

Adult↗
PubMed2005

[Case management of pelvic floor disorders].

Pelvic floor disorders can involve all three parts of the pelvic floor, and must be managed holistically. They are often associated with one another, because they all involve an imbalance between counterbalancing forces, namely abdominal pressure on the one hand and mooring forces on the other hand. The mooring forces consist of 1) the visceral ligaments, which are fibrous cellular condensations around vessels and nerves, connecting the pelvic wall to the organs; 2) the endopelvic fascia; and 3) the pelvic muscles, including the levator ani. The physical examination must be both functional and anatomical, in order to detect obvious and occult disorders of the three parts of the pelvic floor. When physical examination is inadequate, standard radiography or MRI may be used. Radiographic explorations include colpocystography and defecography. The first is carried out in the standing position with a "blocked" perineum, and the second is performed in the defecation position with a "relaxed" perineum. Treatment must take into account dysfunctions, incontinence, and ptosis of the three parts. The author discusses the various examinations and treatments (by the abdominal or vaginal approach), based on published data and personal experience. The choice of treatment always depends on the patient's age, anatomical defects and functional disorders, and the surgeon's expertise

Adult↗
PubMedDate not supplied

Pelvic organ prolapse.

Pelvic organ prolapse, a condition in which the ligaments and muscles that suspend the vagina within the pelvic cavity weaken or break, is a frequent cause of urinary and fecal incontinence. Stigma, embarrassment and the belief that pelvic organ prolapse is a natural part of aging prevents many women from seeking treatment. Medical imaging modalities such as defecography, dynamic magnetic resonance imaging and ultrasound help health care providers make effective treatment decisions.

Diagnostic Imaging↗
PubMed1991

[The continent perineal colostomy after abdominoperineal resection of the rectum. A digital defecographic study].

For 10 years, in the Surgery Dept. of the University of Pisa, perineal colostomies have been performed on patients who had undergone abdominoperineal rectal amputation. The gracilis muscles of the thighs, transposed to the perineum, are used for building a continent muscular apparatus. Seventeen of 40 patients operated with this procedure have been submitted to defecographic studies, by means of digital fluoroscopic image acquisition. This modality allowed the visualization of anastomotic colon morphology as well as of the functionality of the transposed gracilis muscles during the various phases of defecography. The muscle surrounding the colostomy acts as a sphincter and relaxes only during evacuation; the one positioned as a sling acts as the normal puborectalis muscle. In two patients a perineocele was documented, causing problems in the evacuation phase, which were solved after surgical intervention.

Colostomy↗
PubMedDate not supplied

Sensorimotor evaluation of ano-rectal complex in diabetes mellitus.

To evaluate the status of ano-rectal complex in diabetic patients, 20 patients with no fecal incontinence and/or local ano-rectal disorders and 18 normal subjects underwent to: 1) ano-rectal manometry; 2) defecography; and 3) rectal sensation tests. In all subjects, the five classic cardiovascular reflexes tests were performed to detect autonomic neuropathy. No significant difference between diabetic patients and controls was found in length, maximum resting pressure and strength of phasic external anal sphincter or anal canal at ano-rectal manometry; similarly, no significant difference between diabetic and normal subjects was found by the same technique in threshold and amplitude of ano-rectal inhibitory reflex. Ano-rectal angle of diabetic patients was not significantly different from normals both at resting and during straining at defecographic study. By rectal sensation testing, it was possible to demonstrate a significant difference between diabetic and normal subjects in perception of rectal distension (87.5 +/- 27.5 vs 39.2 +/- 6.5 ml, p less than 0.05; mean +/- SEM) and of stimulus of defecation (147.0 +/- 56.3 vs 52.9 +/- 18.5 ml, p less than 0.001) but not in perception of maximum tolerable volume (343.5 +/- 69.9 vs 322.0 +/- 48.5 ml, p = NS). No relationship was found between these results and the score of autonomic neuropathy and/or duration of diabetic disease. These data suggest that an early involvement of only sensory parasympathetic fibers of ano-rectal complex occurs in diabetic patients without gastrointestinal symptoms.

Adolescent↗
PubMedDate not supplied

[Solitary rectal ulcer syndrome].

The solitary rectal ulcer syndrome is an infrequent entity consisting of a rectal lesion, caused by straining during defecation; it is characterized by specific histological changes. The condition is most frequent in adults between 30 and 50 years of age, but a few pediatric cases have been reported. Five patients (4 boys) are presented. All suffered from moderate rectal bleeding, straining, tenesmus and mucous discharge. One of them had clinical and endoscopic evidence of rectal prolapse. On defecography all children showed failure of pelvic floor relaxation during straining. Endoscopic evaluation showed single or multiple ulcers in four patients and a nodular fibrotic lesion in one. The histopathology of the rectal mucosa revealed replacement of the stroma of the lamina propria by collagen, lack of orientation of smooth muscle fibers and considerable hyperthopy of the muscularis mucosae. Medical treatment was satisfactory in four patients, one case required transabdominal rectopexy for relief of his symptoms. The most appropriate form of treatment has not been determined, but surgery should be used when prolapse is a prominent clinical feature. Greater awareness of this condition will lead to more frequent diagnosis.

Adolescent↗
PubMed1991

[Internal intussusception of the rectum. An analysis of 62 cases].

In 62 cases of internal intussusception of the rectum, 21 were treated surgically. Their clinical features included serious dyschesia demanding longer time and strength, tenesmus, and slender stool. Digital examination of the rectum, proctoscopy, and colonoscopy usually showed no abnormalities, while defecography could show the presence and severity of internal intussusception. Parenchymal diseases of the rectum such as carcinomas should be ruled out before surgical correction. Operative measures included rectal suspension raising of the pelvic floor, resection of the redundant sigmoid colon, and the pathogenesis of the disease.

Adult↗
PubMed1991

[Disorders of anorectal function].

Since sophisticated function tests of the anorectal continence organ become more and more available, dysfunction of the anorectum is increasingly diagnosed and differentiated. The examination includes measurements of the pressure in the rectum and anal canal (anorectal manometry), rectal distension by an inflatable balloon to test the sensibility, electromyography and radiological defecography. By these methods the etiology and pathogenesis of the most important anorectal disorders, such as anal incontinence, different forms of constipation and rectal prolapse, may be differentiated. Nowadays, many of these disorders are successfully treated by a specific management which includes a special diet, drugs, surgery and biofeedback training programs.

Anal Canal↗
PubMedDate not supplied

[Defecation disorders. Characteristics of manometric studies and rehabilitation].

The authors review the literature and their personal experience about the systematic exploration of defecation disorders by anorectal manometry and colpocystodefecography. They stress the importance of combining functional and morphological evaluation, in order to avoid inappropriate surgery. Concerning anorectal manometry, the determination of the smallest volume of rectal distention inducing a complete relaxation of the internal anal sphincter was found more useful than the maximal tolerable volume in the exploration of defecation disorders. Finally, the authors report the results of biofeedback conditioning prescribed in 30 patients (27 women, 3 men, mean age: 55 years) with defecation disorders (terminal constipation in 21, fecal incontinence in 9 patients). Several characteristics of anorectal manometry and of defecography were significantly improved after biofeedback conditioning.

Adult↗
PubMed1989

[Possibility of radiology in the study of defection disorders].

Chronic constipation and defecation disorders are a very common disease, but the diagnosis is often unsatisfactory and therefore therapy is mostly inadequate. The purpose of this paper is to demonstrate the contribution of radiological procedures and mainly of the defecography, in improving and determining the diagnosis itself. Many normal and pathological cases are reviewed, described and demonstrated by radiological patterns. Finally, a correct protocol of different procedures, radiological and not, for morphological and functional study of large bowel and pelvis floor is stressed.

Barium Sulfate↗
PubMed1989

[Surgical treatment of severe constipation].

Severe constipation may be treated surgically provided precise evaluation of colon-transit-time and rectal evacuation can be performed. Colon-transit-time may be studied by straight X-ray of the abdomen after oral intake of small plastic markers, and rectal evacuation may be evaluated by defecography. In patients, where Hirschsprung's disease with a short aganglionic segment is suspected, ano-rectal manometry with evaluation of the recto-anal reflex must be performed. Furthermore, electromyography of the external anal sphincter and puborectal muscle during simulated defecation will be necessary in order to evaluate whether obstructed defecation is due to a spastic condition in the anal sphincter or pelvic floor muscles (anismus). Surgical treatment of obstructed defecation depends on the specific pathology, while treatment of slow transit constipation is subtotal colectomy and ileo-rectal anastomosis. In patients, where constipation is based on a combination of obstructed defecation and prolonged colon-transit-time, surgery for obstructed defecation should be carried out first. In patients, where the constipation is due to prolonged colon-transit-time and an adynamic rectum (rectal inertia) without anatomical abnormalities the only possibility of surgical treatment is total colectomy with an ileo-anal pouch.

Constipation↗
PubMedDate not supplied

[Diagnosis and treatment of chronic constipation].

Constipation is a symptom caused by several different pathogenetic mechanisms; it may be secondary to other diseases or be in itself a disease. All patients should perform investigations deemed to exclude or identify known causes of constipation and, in the presence of megarectum, anorectal manometry to detect ultrashort Hirschsprung's disease. In idiopathic constipation, diagnostic work up should attempt to identify alterations of defecation, with defecography, and of colonic propulsion, with gastrointestinal transit time measurement. Evaluation of large bowel segmental transit time, using radiopaque corpuscolate markers, may discriminate patients according to different modalities of transit. Based on a correct diagnostic evaluation the therapeutical approach can be finalized to well defined subgroups of patients. The treatment comprises several types of therapy which may be used alone or in association in the individual patient: bowel training, high residue diets, physiotherapy, bio-feedback, pharmacological therapy, psychiatric therapy, surgery.

Chronic Disease↗