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PubMed1997

Pelvic anatomy and pathology is influenced by distention of the rectum: defecoperitoneography before and after rectal filling with contrast medium.

PURPOSE: The aim of the present study was to evaluate how distention of the rectum with contrast medium at defecoperitoneography affected pelvic anatomy, i.e., position, form, and size, of organs and pouch of Douglas. PATIENTS AND METHODS: Twenty-six female patients with a peritoneocele at defecoperitoneography were selected for the present study. Radiographs taken at the start, before, and after filling the rectum with contrast medium were compared. RESULTS: There was an obvious change in the position of the organs in the pelvis when the rectum was distended with contrast medium. The peritoneocele disappeared completely in 19 of the patients and was reduced in size in the remaining 7 patients, and the enterocele disappeared completely in 13 patients. The small bowel and vaginal portion of the uterus moved cranially. CONCLUSIONS: A distended rectum may conceal existing pathology, such as peritoneocele and enterocele, at defecoperitoneography. Defecoperitoneography should, therefore, include a radiograph before the rectum is filled. This radiograph shows the habitual anatomy of the patient in the sitting position and may demonstrate pathologic findings.

Adult↗
PubMed1997

Anal sphincter reconstruction with a pudendal nerve anastomosis following abdominoperineal resection: report of a case.

PURPOSE AND METHODS: We report herein a case of a patient with rectal carcinoma in whom a new anus was constructed following an abdominoperineal resection of the anorectum. This is the first reported case in which reconstruction of the anal sphincter was performed using the lower part of the gluteus maximus muscle with a pudendal nerve anastomosis. The pudendal nerve anastomosis maneuver was designed to achieve proper innervation and function of the external anal sphincter. This newly reconstructed sphincter was physiologically evaluated after surgery. RESULTS: The patient's defunctioning colostomy was not closed following his initial surgery because part of the transposed muscle was devitalized by infection following blood flow damage. However, purposeful contraction of the new sphincter was easy to achieve without special training. The patient's rectal sensation for the desire to defecate was satisfactory. Electromyographic studies demonstrated that the newly reconstructed anal sphincter had characteristics of the original external anal sphincter. CONCLUSIONS: This method is a promising procedure for reconstructing the anal sphincter.

Aged↗
PubMed2001

A comparison between dynamic pelvic magnetic resonance imaging and videoproctography in patients with constipation.

PURPOSE: This study attempts to compare the diagnostic efficacy of dynamic pelvic magnetic resonance imaging with that of videoproctography for the presence of rectocele, sigmoidocele, and intussusception as well as the measurement of anorectal angle and perineal descent in constipated patients. METHODS: Patients volunteering for the study and fulfilling the criteria for videoproctography to evaluate constipation were also scheduled for dynamic pelvic magnetic resonance imaging. Patients undergoing videoproctography were placed in the left lateral decubitus position, after which 50 ml of liquid barium paste was introduced into the rectum. After this, approximately 100 ml of thick barium paste similar to stool in consistency was injected into the rectum, and the patient was instructed to defecate while video images were taken. For dynamic pelvic magnetic resonance imaging, air, to be used as contrast, was allowed to accumulate in the rectum via examination with the patient in the prone position. A capsule was taped to the perineal skin immediately posterior to the anal orifice for marking. Sagittal and axial T1 images were obtained through the pelvis at 8-mm intervals with dynamic breathhold sagittal images of the anorectal region obtained at rest and during strain and squeeze maneuvers. Total acquisition time per maneuver was approximately 19 seconds. The tests were performed by different examiners blinded to the result of the other evaluation. The investigations were independently interpreted, findings compared, and patients questioned regarding their impression of dynamic pelvic magnetic resonance imaging and videoproctography. RESULTS: From June 1996 to April 1997, 22 patients (15 females) with a mean age of 68 (range, 21-85) years underwent both videoproctography and dynamic pelvic magnetic resonance imaging. Dynamic pelvic magnetic resonance imaging was only able to detect 1 of 12 (8.3 percent) anterior rectoceles and one of two (50 percent) posterior rectoceles identified by videoproctography. It failed to recognize any of the rectoanal intussusception (zero of four) but did show 9 of 12 (75 percent) sigmoidoceles. Significant discrepancy of measurement of the anorectal angle and perineal descent exists between the two studies, and dynamic pelvic magnetic resonance imaging was not able to detect any (0 of 11) of the patients with increased fixed perineal descent and only half (one of two) of the patients with increased dynamic perineal descent noted on videoproctography. All 22 patients preferred dynamic pelvic magnetic resonance imaging over videoproctography because of greater comfort. CONCLUSION: Occasionally, the increased cost of new technology can be justified by the enhanced diagnostic yield. The ability to avoid unnecessary surgery or, conversely, to continue to search for otherwise occult pathology that can be surgically corrected justifies routine application of these new tools. However, this study has shown that, despite a cost of approximately ten times more for dynamic pelvic magnetic resonance imaging than for videoproctography, no clinical changes were made. Thus, on the basis of this study, we cannot endorse the routine application of dynamic pelvic magnetic resonance imaging for the evaluation of constipated patients. In certain selected individuals, it may play a role, but further study is necessary to clarify its exact role.

Adult↗
PubMed2000

Rectal akinesia as a new cause of impaired defecation.

PURPOSE: The aim of this prospective study was to point out a new concept of dyschezia using dynamic videoproctography. METHODS: A total of 154 consecutive patients with impaired defecation prospectively underwent dynamic videoproctography from 1996 to 1998. Evacuation of thick barium of standardized consistency was fully videotaped under fluoroscopy in the sitting position. We measured the weight of barium injected into the rectum (Q1 in g), the weight of barium evacuated (Q2 in g) and the time for rectal evacuation (t in seconds). Flow rate and postdefecation residue were given by calculating Q2/t and (Q1 - Q2) X 100/Q1, respectively. We studied all patients whose flow rate and postdefecation residue were less than 5 g/second and more than 30 percent, respectively. These values were arbitrarily chosen, based on rectal evacuation in 25 controls (5 healthy volunteers together with 20 patients without dyschesia). RESULTS: Nine of 154 patients with dyschesia fulfilled the criteria and had none of the usually known causes of dyschezia, such as anismus, megarectum, intussusception, rectal prolapse, rectocele, or enterocele. These nine patients had a normal rectal anatomic appearance and a wide-open short anus but despite exhausting straining efforts were unable to obtain total rectal emptying. Dynamic videoproctography brings strong arguments for an absence of rectal wall contraction, despite normal functioning pelvic floor. CONCLUSIONS: Dynamic videoproctography allows identification of new features in patients with dyschesia: very slow defecation flow rate and high postdefecation residue. This new concept could be called rectal akinesia by analogy with bladder akinesia in some dysuric patients.

Administration, Rectal↗
PubMed2003

Diagnosis of cystocele--the correlation between clinical and radiological evaluation.

In patients with genital prolapse involving several compartments simultaneously, radiologic investigation can be used to complement the clinical assessment. Contrast medium in the urinary bladder enables visualization of the bladder base at cystodefecoperitoneography (CDP). The aim of the present study was to evaluate the correlation between clinical examination using the Pelvic Organ Prolapse Quantification system (POP-Q) and CDP. Thirty-three women underwent clinical assessment and CDP. Statistical analysis using Pearson's correlation coefficient ( r) demonstrated a wide variability between the current definition of cystocele at CDP and POP-Q ( r=0.67). An attempt to provide an alternative definition of cystocele at CDP had a similar outcome ( r=0.63). The present study demonstrates a moderate correlation between clinical and radiologic findings in patients with anterior vaginal wall prolapse. It does not support the use of bladder contrast at radiologic investigation in the routine preoperative assessment of patients with genital prolapse.

Adult↗
PubMed2002

Cystodefecoperitoneography in patients with genital prolapse.

The aim of the study was to prospectively evaluate pre- and postoperative findings of cystodefecoperitoneography (CDP) and to correlate the findings to the clinical examination in patients with genital prolapse. Twenty-five female patients were investigated both pre- and postoperatively with a standardized questionnaire, clinical examination and CDP, including contrast medium in the rectum, vagina, bladder, small bowel and peritoneal cavity. At preoperative clinical examination a rectocele was diagnosed in 24 patients, a cystocele in 7 and an enterocele in 2. At the preoperative CDP a rectocele was diagnosed in 21 patients, a cystocele in 22 patients and a peritoneocele in 9, of which six contained small bowel (i.e. an enterocele). Surgery was performed according to the clinical findings. At the postoperative clinical examination no rectocele was diagnosed, a cystocele was diagnosed in 3 patients and an enterocele in 1. Postoperative CDP showed a rectocele in 4 patients, a cystocele in 24 and a peritoneocele in 7 patients, of which three contained small bowel (i.e. an enterocele). CDP may complement the clinical assessment of patients with genital prolapse, in particular to confirm or detect defects involving the posterior compartment. The radiologic definition of cystocele needs further evaluation.

Adult↗
PubMedDate not supplied

Barium trapping in rectoceles: are we trapped by the wrong definition?

BACKGROUND: Barium trapping within a rectocele is a criterion used by surgeons to select which patients with rectoceles should undergo operative repair. This proctographic study compared the presence and depth of barium trapping within a rectocele on postevacuation radiography with those seen on posttoilet radiography after further evacuation in the privacy of the bathroom. METHODS: Eighty-two consecutive patients with evidence of barium trapping on postevacuation radiographs of a fluoroscopic dynamic cystoproctographic examination were reviewed retrospectively. The size of the rectoceles and the depth of barium trapping on the postevacuation and subsequent posttoilet radiographs were measured. RESULTS: The posttoilet radiographs showed resolution of the barium trapping in 47 (57%) of the 82 patients. Resolution of the trapping was directly related to rectocele size. The mean differences in the depth of barium trapping between the postevacuation and posttoilet radiographs were significant for all sizes of rectocele. CONCLUSION: Barium trapping in rectoceles changes with the degree of rectal evacuation. More complete evacuation was shown on the posttoilet radiograph than on the postevacuation radiograph. Consequently, the posttoilet radiograph may be more appropriate for the preoperative assessment of barium trapping within rectoceles.

Barium Sulfate↗
PubMed2003

Videodefecography: a study of the rectal motile pattern.

The mechanism of rectal motility has remained largely obscure. Recently, by recording rectal electromechanical activity, we identified the rectal motility pattern as occurring in a "mass squeeze" manner. In the current communication, rectal motility was studied by means of videodefecography. The study comprised 28 healthy volunteers (18 men, 10 women; mean age 37.6+/-11.8 years). Evacuation dynamics were studied and registered using a videocassette tape with a high-resolution recorder. The rectum showed no peristaltic or segmentation activity at rest. When the subject was asked to evacuate, a contraction wave started at the rectosigmoid junction (RSJ) and spread aborally. The upper rectum appeared to contract producing anal canal opening and the closure of the RSJ; after rectal evacuation, the anal canal closed and the RSJ opened. The rectal contraction wave was repeated as long as the rectum still contained barium paste. The subjects strained prior to the start of each contraction wave. Some waves did not effect rectal evacuation. These "incomplete" waves started at the mid- or lower rectum and were followed by "complete" waves that produced evacuation. In five of 28 subjects, rectal intussusception occurred during rectal contraction. A small anterior rectocele occurred in another two subjects during rectal contraction. Videodefecography revealed that upon rectal distension with barium paste, a contraction wave, initiated at the RSJ, effected reflex RSJ closure and anal canal opening. The wave spread aborally, "squeezing" the rectal contents towards the opened anal canal. Two types of contraction waves were observed: "complete" which produced rectal evacuation, and "incomplete" which failed to effect evacuation. Physiologic intussusception or rectocele were seen in a few subjects.

Adult↗
PubMed2001

Imaging of the posterior pelvic floor.

Disorders of the posterior pelvic floor are relatively common. The role of imaging in this field is increasing, especially in constipation, prolapse and anal incontinence, and currently imaging is an integral part of the investigation of these pelvic floor disorders. Evacuation proctography provides both structural and functional information for rectal voiding and prolapse. Dynamic MRI may be a valuable alternative as the pelvic floor muscles are visualised, and it is currently under evaluation. Endoluminal imaging is important in the management of anal incontinence. Both endosonography and endoanal MRI can be used for detection of anal sphincter defects. Endoanal MRI has the advantage of simultaneously evaluating external sphincter atrophy, which is an important predictive factor for the outcome of sphincter repair. Many aspects of constipation and prolapse remain incompletely understood and treatment is partly empirical; however, imaging has a central role in management to place patients into treatment-defined groups.

Constipation↗
PubMed2007

Ultrasonographic patterns in patients with obstructed defaecation.

BACKGROUND: Anal ultrasound is helpful in assessing organic anorectal lesions, but its role in functional disease is still questionable. The purpose of the present study is to assess anal-vaginal-dynamic perineal ultrasonographic findings in patients with obstructed defecation (OD) and healthy controls. MATERIALS AND METHODS: Ninety-two consecutive patients (77 women; mean age 51 years; range 21-71) with symptoms of OD were retrospectively evaluated. All patients underwent digital exploration, endoanal and endovaginal ultrasound (US) with rotating probe. Forty-one patients underwent dynamic perineal US with linear probe. Anal manometry and defaecography were performed in 73 and 43 patients, respectively. Ultrasonographic findings of 92 patients with symptoms of OD were compared to 22 healthy controls. Anismus was defined on US when the difference in millimetres between the distance of the inner edge of the puborectalis muscle posteriorly and the probe at rest and on straining was less then 5 mm. Sensitivity and specificity were calculated by assuming defaecography as the gold standard for intussusception and rectocele and proctoscopy for rectal internal mucosal prolapse. Since no gold standard for the diagnosis of anismus was available in the literature, the agreement between anal US and all other diagnostic procedures was evaluated. RESULTS: The incidence of anismus resulted significantly higher (P < 0.05) in OD patients than healthy controls on anal (48 vs 22%), vaginal (44 vs 21%), and dynamic perineal US (53 vs 22%). A significantly higher incidence of rectal internal mucosal prolapse was observed in OD patients when compared to healthy controls on both anal (61.9 vs 13.6%, P < 0.0001) and dynamic perineal US (51.2 vs.9% P = 0.001). For the diagnosis of rectal internal mucosal prolapse, anal US had a 100% sensitivity and specificity. For diagnosis of rectal intussusception, anal US had an 83.3% sensitivity and 100% specificity and perineal US had a 66.6% sensitivity and 100% specificity. In the diagnosis of anismus, anal ultrasonography resulted in agreement with perineal and vaginal US, manometry, defaecography, and digital exam (P < 0.05). Other lesions detected by US in patients with OD include solitary rectal ulcer, rectocele and enterocele. Damage of internal and/or external sphincter was diagnosed at anal US in 19/92 (20%) patients, all continent and with normal manometric values. CONCLUSION: Anal, vaginal and dynamic perineal ultrasonography can diagnose or confirm many of the abnormalities seen in patients with OD. The value of the information obtained by this non-invasive test and its role in the diagnostic algorithm of OD is yet to be defined.

Adult↗
PubMed2001

Contribution of posture to the maintenance of anal continence.

The anorectal angle (ARA) is believed to provide one of the most important contributions to anal continence. The normal resting angle is approx. 90 degrees, but the erect position may modify the ARA and other parameters usually considered in a proctometrogram. We compared the proctometrogram in different postures to elucidate the role of changes in the ARA in maintaining fecal continence. Sixty-three patients with constipation underwent static proctography. Variations in the ARA, perineal descent, puborectalis muscle length, and pubococcygeal distance were determined during resting, squeezing, and pushing with the patient in the Sims' position (SP); further evaluations used radiographs in resting position but with straight legs, in erect and sitting positions. The resting mean ARA was 95.3 +/- 15 degrees in SP and 79.8 +/- 14 degrees standing erect; the latter value was also significantly less during squeezing (84 +/- 11 degrees). The mean ARA during pushing was 118 +/- 16 degrees. A systematic and statistically significant difference in the mean resting ARA was demonstrated using the baseline of the rectal shape instead of the major rectal axis when measuring the anorectal angle. When sitting on a toilet, the mean resting ARA was significantly wider than in SP. The length of the puborectalis sling at rest did not change but was significantly reduced during squeezing and increased during pushing. The descent of the perineum at rest was near to 0 (-0.089 +/- 1.76 cm) in SP and significantly less when standing (-0.65 +/- 1.9 cm) and during squeezing (-0.97 +/- 1.7 cm). Perineal descent during pushing was +2.94 +/- 2.2 cm. The mean pubococcygeal distance did not change significantly in SP and in the erect position. The erect position thus contributes significantly to the maintenance of fecal continence by sharpening the ARA. This effect is stronger than any active contraction of the puborectalis muscle and is not related to shortening of the puborectalis sling but is secondary to lifting of the pelvic floor.

Adult↗
PubMed1999

Cinedefecographic evidence of difficult evacuation in constipated patients with complex symptoms.

Patients with constipation may have various pelvic complaints of difficult evacuation coexisting with infrequent evacuation and other abdominal complaints, and the overlapping of symptoms makes it difficult to select appropriate therapy based on clinical history and routine office examination alone. Cinedefecography is an objective method for examining patients who have complex subjective symptoms. This study assessed the value of cinedefecography for evaluating patients with constipation with multiple complaints. We divided 185 patients with constipation into two those with (group 1) or without (group 2) cinedefecographic evidence of difficult evacuation. These groups were compared relative to complaints, manometric results, cinedefecography findings, and the success of biofeedback treatment. Group 1 patients were further evaluated according to the type of abnormal findings: sigmoidocele, rectocele, intussusception, and perineal descent. We found no significant differences in patient complaints between the groups. However, there were more patients in group 2 with intussusception than in group 1; there were also significant differences between the groups in mean resting pressure, maximum resting pressure, and maximum squeeze pressure. In group 1 patients with rectocele complained more frequently of excessive straining, and those with intussusception complained more frequently of incomplete evacuation. Sensory threshold and maximal tolerable capacity were significantly higher in patients with intussusception. Rectocele was predominant in women, and biofeedback treatment was extremely advantageous (86%) for patients in group 1 with a rectocele in association with other pathology. Whether the intussusception or the descent causes decreased mean resting and mean and maximum squeeze pressures is unknown but is an additional and potentially important finding which needs further elucidation for it to have therapeutic significance.

Adolescent↗
PubMed2001

Postoperative fecoflowmetric analysis in patients with anorectal malformation.

Because conventional methods of evaluating anorectal function do not necessarily provide good correlations between investigative results and symptoms in patients who have undergone surgery for an anorectal malformation (ARM), we recently introduced feco-flowmetry (FFM) to simulate natural anorectal evacuation. The purpose of this study was to embody significant parameters to elucidate the dynamics of anorectal activity on FFM. The parameters of FFM were compared with those of manometry and Kelly's clinical score (KCS) in 24 patients who underwent surgery for an ARM. There were three fecoflow patterns, namely, block (B) type, segmental (S) type, and flat (F) type. The B-type or S-type patterns were seen in patients classified as "clinically good." There were close relationships between the fecoflow pattern and both the operative procedure and the KCS (P = 0.01 and 0.001, respectively). Maximum fecal stream flow rate (Fmax) precisely reflected the tolerance rate of intended normal saline solution in the colorectum (TR), the evacuative rate (ER), and KCS. Fmax > 45 ml/s or TR > 70% or ER > 50% was statistically regarded as the borderline of fecal continence. Thus, the fecoflow pattern might reflect the motor activity of the pelvic floor muscle. FFM provided quantiative and qualitative evaluations concerning anorectal motor activity in patients who had undergone surgery for an ARM.

Adolescent↗
PubMed2005

Anorectal manometry: are fatigue rate and fatigue rate index of any clinical importance?

BACKGROUND: Loss of voluntary contraction of the external anal sphincter is thought to be a factor in fecal incontinence. During anal manometry, computerized systems produce several parameters including fatigue rate (FR), which is the basis for calculating the fatigue rate index (FRI). Our aim was to evaluate FR and FRI and their clinical importance in patients suffering from fecal incontinence or severe constipation. MATERIALS AND METHODS: All patients scheduled for an anal physiology work-up were included in the study. FR was determined by a computer program and FRI was calculated manually with the following equation: FRI (minutes) = [squeeze pressure (mm Hg) - resting pressure (mmHg)] / - FR (mmHg/min). FR and FRI were compared in patients suffering from fecal incontinence (group I) and severe constipation (group II). Furthermore, subgroups (<50 and > or = 50 years of age) were compared. Lastly, a possible relation between length of the high-pressure zone (HPZ) and FR and FRI was assessed. RESULTS: Between January 2000 and December 2004, 131 patients (96 with fecal incontinence, 35 with constipation) were studied. Both FR and FRI were similar between groups I and II; no significant differences were found when younger and older patients were compared within the same group. We also did not find any relation between HPZ length and either FR or FRI. CONCLUSIONS: FR and FRI do not seem to be helpful in routine colorectal practice for evaluating the strength of the external anal sphincter.

Adult↗
PubMed2002

Anal manometric predictors of significant rectocele in constipated patients.

The diagnosis of significant rectocele is currently made on the basis of cinedefecographic findings. Clinical examination alone will only allow assessment of the presence but not the significance of a rectocele. Therefore, the aim of this study was to determine if anal manometric findings can predict the significance of a rectocele. All patients with a diagnosis of constipation and rectocele confirmed on cinedefecography between 1992 and 1998 were retrospectively reviewed. Significant rectocele was defined as the presence of three of the following five parameters: rectocele >4 cm in diameter as measured during the evacuatory phase of cinedefecography, rectal and/or vaginal symptoms present for longer than 12 months, persistence of rectal or vaginal symptoms for at least four weeks, despite increased dietary fiber (up to 35 g/day), need for rectal and/or vaginal digitation or perineal support maneuvers for rectal evacuation. Statistical analysis was performed using the Mann-Whitney test and Fisher's exact test. A logistic regression model with stepwise selection was used to determine significant prognostic factors. A total of 305 patients (31 men) with rectocele, with a median age of 68 years (range, 12-89) were identified. Of these, 89 (29.2%) had significant rectoceles. There was no difference in the frequency of significant and non-significant rectoceles with respect to gender or age. However, patients with a significant rectocele compared to those with a non-significant rectocele had higher median first sensation volume (45 vs. 30 ml, p=0.0005), median capacity (160 vs. 120 ml, p<0.0001), and median compliance (10 vs. 8 ml H(2)O/mmHg, p=0.05). Calculations based on a logistic regression model determined that with a first sensation of 100 ml, a capacity of 400 ml, and a compliance of 50 ml/mmHg, the probability of a significant rectocele would be 85%. In conclusion, anal manometric findings may be useful in predicting significant rectocele in constipated patients.

Adolescent↗