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PubMed1993

Does perineal descent correlate with pudendal neuropathy?

A prospective study was undertaken to assess the potential correlation between increased perineal descent (IPD) and pudendal neuropathy (PN) in 213 consecutive patients. These 165 females and 48 males of a mean age of 62 (range, 18-87) years had constipation (n = 115), idiopathic fecal incontinence (n = 58), or chronic intractable rectal pain (n = 40). All 213 patients underwent cinedefecography (CD) and bilateral pudendal nerve terminal motor latency (PNTML) assessment. Perineal descent (PD) of more than the upper limit of normal of 3.0 cm during evacuation was considered increased. Pudendal neuropathy was diagnosed when PNTML exceeded the upper limit of normal of 2.2 milliseconds. Although 65 patients (31 percent) had PD, only 16 (25 percent) of these 65 patients had neuropathy. Moreover, PN was also found in 42 (28 percent) of 148 patients without IPD. Conversely, only 16 (28 percent) of the 58 patients who had PN also had IPD, and IPD was present in 49 (32 percent) of 155 patients without PN. The frequency of PN according to the degree of IPD was: 3.0 to 4.0 cm, 6 of 27 patients (22 percent); 4.1 to 5.0 cm, 4 of 15 (27 percent); 5.1 to 6.0 cm, 4 of 12 (25 percent); 6.1 to 7.0 cm, 2 of 8 (25 percent); and > 7.0 cm, 0 of 3 (0 percent). Linear regression analysis was undertaken to compare the relationships between measurements of PD at rest (R), push (P), and change (C = P-R) and values of PNTML. These values for all 213 patients were: R, r = 0.048; P, r = 0.031; and C, r = -0.050. The correlation coefficients were equally poor for all the individual subgroups analyzed, including the patient's sex or diagnosis. In summary, no correlation was found between PD and PNTML. The lack of a relationship was seen for the entire group as well as for those patients with either neuropathy or increased perineal descent. Therefore, the often espoused relationship between increased PD and PN was not supported by this prospective evaluation. Although increased PD and prolonged PNTML are frequently observed in patients with disordered defecation, they may represent independent findings.

Adolescent↗
PubMed1994

Manometric study of the voluntary inhibition action in normal volunteers.

PURPOSE: A voluntary inhibition action whereby a voluntary squeeze of the external sphincter causes reflex relaxation of the rectum has been previously proposed but not proven. Such a reflex would enable the subject to defer defecation to a socially acceptable time. The purpose of this study was to determine whether or not such a reflex exists. METHODS: We measured rectal compliance with and without a voluntary squeeze using a specially designed balloon catheter in nine subjects. RESULTS: When corrected for increased intra-abdominal pressure caused by inadvertent Valsalva's maneuver during voluntary squeezing, there was a significant increase in rectal compliance during voluntary contraction of the external sphincter (P < 0.01). CONCLUSION: This lends support to the proposed existence of the voluntary inhibition action.

Adult↗
PubMed1994

Enterocele is correctable using the Ripstein rectopexy.

PURPOSE: About one-third of the patients with rectal prolapse or rectal intussusception have concurrent enterocele at defecography. The purpose of this study was to evaluate the effect of the Ripstein procedure on the concurrent enterocele and to study the outcome of the procedure with respect to the patients' symptoms. METHODS: Twenty-two patients with enterocele and either rectal prolapse or rectal intussusception at defecography were treated using the Ripstein procedure. Postoperatively, the patients were evaluated with clinical examination (22 patients) and defecography (16 patients). RESULTS: None of the patients had recurrence of enterocele, rectal prolapse, or intussusception at postoperative follow-up. Continence was improved in 15 of 16 incontinent patients. Emptying difficulties were unchanged in eight patients, improved in five patients, and had deteriorated in four patients. CONCLUSIONS: Enterocele is corrected by using the Ripstein rectopexy. Persisting defecation difficulties after the Ripstein procedure are unlikely to be secondary to enterocele. The Ripstein procedure can be an alternative in the treatment of enterocele, as a majority of these patients also have rectal prolapse or rectal intussusception.

Defecation↗
PubMed1994

Abdominal rectopexy for rectal prolapse. Influence of surgical technique on functional outcome.

PURPOSE: The aim of this study was to investigate the influence of surgical technique on functional and manovolumetric results in patients treated with Marlex mesh abdominal rectopexy. METHODS: The lateral ligaments were completely divided (the Wells procedure) in 16 patients and preserved (the Ripstein procedure) in 16 patients. Clinical and physiologic assessment were performed before and at 3, 6, and 12 months after operation. RESULTS: Improvement of continence was similar. Bowel regulation problems which were unchanged after the Ripstein procedure increased significantly after the Wells procedure (P < 0.01). Rectal volume became reduced in the group who received the Wells procedure (225 ml vs. 115 ml, P < 0.05 at one year), but remained unchanged after receiving the Ripstein procedure. The pressure thresholds required to elicit sensation of rectal filling and defecation urge were increased after the Wells procedure (15 cm of H2O vs. 25 cm of H2O, P < 0.05 and 25 cm of H2O vs. 45 cm of H2O, P < 0.05, respectively). In the Ripstein group there was only a slight increase of the threshold for urge (P < 0.05). CONCLUSION: The Wells procedure was followed by severe rectal dysfunction accompanied by increased constipation and evacuation problems. The Ripstein procedure, preserving the lateral ligaments, appears not to affect such symptoms adversely. On the other hand, improvement is not likely to occur.

Defecation↗
PubMed1992

What is the meaning of colorectal transit time measurement?

This study was done to understand the different available methods used to calculate colorectal transit times. A single abdominal radiograph is taken following six successive daily ingestions of the same number of identical radiopaque markers. This method correlates well (P less than 0.001) with that using a single ingestion of markers with daily x-ray films until total expulsion. In techniques used to measure colorectal transit time with multiple ingestion of markers, the number of days of ingestion depends on the kinetics of marker defecation. This was found to differ markedly in various groups of control subjects and constipated patients (P less than 0.001) and can be used to obtain reliable data, even in subjects with severe constipation. When they ingest 20 markers, constipated patients are found to retain eight or more markers three days after ingestion, and taking a plain film of the abdomen on that day is sufficient to make a diagnosis of constipation. Transit time studies are reproducible from month to month in patients with an irritable bowel syndrome. Control subjects who claim that their bowel habits are not modified by stress have shorter transit times, similar in both sexes, than those who say they are (P less than 0.001). This may explain why a large percentage of constipated patients have been found by most authors to have "normal" colorectal transit times. The choice of control subjects is thus a key element in studies of functional bowel motor disorders. Stool frequency and consistency, in health, correlate only to rectosigmoid transit time.

Adult↗
PubMed1991

Physiologic and anatomic assessment of patients with rectocele.

Clinical, physiologic, and anatomic assessments were carried out in 22 female patients with symptomatic rectocele (Group A), 15 patients with asymptomatic rectocele (Group B), and 14 subjects having no rectocele (Group C). Resting and pressure, rectal pressure, rectal compliance, anorectal inhibitory reflex, and rectal sensation did not differ among the groups. Proctography revealed that the lengths of the rectocele during attempted defecation in groups A (1.6 [1.0-3.5] cm) (median and range) and B (1.6 [1.0-3.0] cm) were significantly greater than that in Group C (0.4 [0.1-0.9] cm) (P less than 0.001 in both groups). Median pelvic floor descent at rest in Groups A (4.3 [1.6-7.5] cm) (median and range) and B (4.3 [1.3-6.9] cm) were significantly greater than that in Group C (2.5 [1.2-5.0] cm) (P less than 0.001 and P less than 0.02, respectively). These results indicate that rectocele is not associated with any physiologic change apart from a significant increase of pelvic floor descent.

Adult↗
PubMed1997

Physiology of rectal sensations: a mathematic approach.

PURPOSE: The first awareness of balloon inflation (first sensation (FS)), flatus sensation (constant sensation (CS)), urge to defecate (UD), and maximum tolerated threshold (MTT) are the four commonly evaluated rectal sensations. The traditional view that these sensations are attributable to pelvic floor mechanoreceptor stimulation is challenged by current evidence in favor of rectal wall mechanoreceptors. The aim of this study was to determine the physiology of these sensations, using a dynamic mathematic model of the rectum. METHODS: In a group of 15 healthy adult volunteers (11 female and 4 male; median age, 51.5 (range, 31-74) years), the polynomial behavior of the two smooth muscle components of a dynamic mathematic model of the rectum was analyzed to find strain levels of smooth muscle activity in relation to corresponding strain levels of each of the four "rectal" sensations. RESULTS: Longitudinal and circular smooth muscle relaxation appeared to be the rate detection and signaling mechanisms, respectively. The latter triggered sensations of CS, UD, and MTT. FS was an anal canal sensation, related temporally with onset of rectoanal inhibitory reflex. In vitro validation of the model suggested MTT to be a physiologic protective mechanism associated probably with tetanic smooth muscle contraction. CONCLUSIONS: Evaluation of rectal sensations should be confined to CS and UD because MTT is painful and does not contribute any additional information, and FS is not a true rectal phenomenon.

Adult↗
PubMed1997

Physiologic characteristics of straight and colonic J-pouch anastomoses after rectal excision for cancer.

PURPOSE: The colonic J-pouch anastomosis has been advocated to obviate urgent and frequent defecations following a sphincter-saving rectal excision. Physiologic characteristics of the colonic J-pouch were compared with those of the traditional straight anastomosis and related to clinical function. METHOD: Patients with total mesorectal excision for carcinoma were randomized to either a straight (n = 23) or a colonic pouch anastomosis (n = 23). The patients were examined before and at one year after surgery (n = 42), which included laboratory studies, and a questionnaire regarding anorectal function was completed. RESULTS: Preoperative compliance of the rectum was restored after surgery in the pouch group, 2.9 (2.2-3.4) ml/cm H2O, but there was a significant decrease after surgery in the straight anastomosis group, 1.9 (1.1-2.3) P < 0.001 (median (interquartile range)). Sphincter pressures in both groups were similar. In a multiple regression analysis, high compliance was associated with favorable clinical function, and hypermotility of the anal canal was associated with adverse clinical function. CONCLUSIONS: Colonic pouch-anal anastomosis restores neorectal compliance, which is important for good function after low anterior resection. Presence of an unstable internal sphincter is a negative factor for clinical function in both straight and pouch anastomoses.

Adult↗
PubMed1991

What affects continence after anterior resection of the rectum?

Functional results after anterior rectal resections are commonly considered satisfactory but variable percentages of postoperative incontinence are often reported. Continence was evaluated after 20 low anterior resections (LAR) and 13 high anterior resections (HAR) by means of clinical assessment, anorectal manometry, and evacuation proctography. Whereas all HAR patients had perfect continence, 10 patients (50 percent of the LAR group had occasional episodes of soiling from liquid feces, 5 patients (25 percent had frequent soiling or occasional incontinence for solid feces, and 1 patient (5 percent had frequent solid stool loss requiring surgical treatment. Anal canal resting pressure at 3 and 4 cm from the anal verge was significantly lower in the LAR group (P less than 0.02 and P less than 0.05, respectively) than in the HAR group. However, the maximum voluntary contraction did not differ between the two groups. Rectoanal inhibitory reflex was found to be present in 17 of the 20 patients with LAR and in all patients with HAR. The volume at which the anal sphincter is continuously inhibited was significantly reduced in the LAR group (P less than 0.001). Also, the conscious rectal sensibility volumes were found to be significantly reduced for threshold, constant, and maximum tolerated volume. Threshold volume for internal sphincter relaxation was lower than the threshold volume for rectal sensation in some patients with LAR. This could allow postoperative fecal soiling. Rectal compliance was decreased (P less than 0.001) in the LAR group. Evacuation proctography, performed in six LAR patients affected by major soiling or solid stool loss, revealed an abnormal obtuse anorectal angle and pathologic lowering of the perineum at rest and during defecation. The concomitance of internal and sphincter impairment, reduction in rectal compliance, and previous pelvis floor muscle damage are postulated as cause affecting continence in patients who underwent LAR.

Anal Canal↗
PubMed1992

Influence of myectomy, ileal valve, and ileal reservoir on the ecology of the ileum.

Fecal bacteriology, fecal volatile fatty acids, and ileal mucosal morphology were studied in dogs after ileoanal anastomosis alone, ileoanal anastomosis and myectomy, ileoanal anastomosis and myectomy with ileoileal valve, and ileoanal anastomosis with duplicated (J) ileal reservoir. The ratio of anaerobes to aerobes was significantly less in stool from dogs which had undergone ileoanal anastomosis compared with each of the other three groups (P less than 0.01). The numbers of streptococci and clostridia both were significantly less in stool from dogs with ileoanal anastomosis alone than in any other group. The concentrations of fecal acetic and propionic acids were significantly less in dogs with ileoanal anastomosis alone than in any other group (P less than 0.05), but there were no significant differences in the concentrations of fecal butyric or valeric acids. The severity of mucosal inflammation and degree of villous atrophy were more marked in the ileum of J reservoirs (P less than 0.01), and the percentage of stool retained after defecation was greater (P less than 0.05) in dogs with J reservoirs than in any other group. Therefore, the use of myectomy resulted in significant changes in the ecology of the distal ileum although changes typical of pouchitis were seen only in dogs with J reservoirs.

Animals↗
PubMed1997

Are special investigations of value in the management of patients with fecal incontinence?

PURPOSE: The aim of this study was to determine whether special investigations significantly alter either the diagnosis or the management plan of patients with fecal incontinence assessed on the basis of a structured history and physical examination alone. METHODS: Fifty consecutive patients with fecal incontinence were prospectively studied in a tertiary referral clinic. Each patient was assessed by two clinicians who independently formulated a diagnosis and treatment plan based on the history and physical examination. The resulting 100 patient assessments were then compared with the final diagnosis and treatment plan formulated on completion of endoanal ultrasound, anal manometry, external sphincter electromyography, and defecating proctography. RESULTS: In the assessment of fecal incontinence, the addition of special investigations altered the diagnosis of the cause of incontinence based on history and examination alone in 19 percent of cases. The management plan was altered in 16 percent of cases. Special investigations were most useful in separating neuropathy from rectal wall disorders and in demonstrating the unexpected presence of internal sphincter defects and neuropathy. CONCLUSIONS: Even experienced colorectal surgeons will misdiagnose up to one-fifth of patients presenting with fecal incontinence if assessment is based on the history and physical examination alone. However surgically correctable causes of incontinence are rarely missed on clinical assessment.

Anal Canal↗
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↗
PubMed1990

Adult Hirschsprung's disease. Clinical features and functional outcome after surgery.

To assess the clinical features and long-term functional outcome after surgery, eight patients operated on for adult Hirschsprung's disease during the 20-year period, 1968-1988, were re-examined. There were six men and two women with a mean age of 40 +/- 3 years at the time of survey. The mean age of the patients at the time of diagnosis was 23.8 years (range, 16 to 41 years). Results were compared with eight consecutive patients operated on for Hirschsprung's disease during the neonatal period. The Duhamel operation was performed initially on seven patients in the adult group and on all patients in the neonatal group. Anterior resection was performed on one adult patient initially but this was converted subsequently to Soave's pull-through operation. None of the patients had constipation after definitive surgery. The mean defecation frequency was two in both groups. Three patients in the adult group and two patients in the neonatal group were completely continent, others had occasional soiling. The mean anal sphincter pressures were lower in the neonatal group than in the adult group and in each group lower than in normal controls. Adult Hirschsprung's disease must always be suspected in the context of chronic constipation. Functional results after surgery in adult patients are similar to those achieved in children.

Adult↗
PubMed1992

Anorectal pressure gradient in patients with anal incontinence.

Anorectal pressures in patients with fecal incontinence have been investigated. With anal manometry, 34 percent of patients with fecal incontinence had maximal resting pressure and 39 percent had maximal squeeze pressure within the normal range. When a pressure gradient was calculated as the pressure difference between maximal resting pressure and rectal pressuring during filling of a rectal balloon, patients with fecal incontinence could be better distinguished from controls: 20 percent of patients with fecal incontinence had values within the normal range when the rectal pressure at the earliest defecation urge was used (P less than 0.05), and 12 percent had values within the normal range when the rectal pressure at maximal tolerable volume was used (P less than 0.01). Anorectal pressure gradient measurements seem to distinguish patients with fecal incontinence from controls better than maximal resting pressure or maximal squeeze pressure alone.

Adult↗
PubMed1993

Functional changes associated with short and long lateral ileal reservoirs in a canine model.

Colectomy and endorectal ileal pull-through with ileal reservoir (PTR) have become a standard operative procedure for severe ulcerative colitis and familial polyposis coli. Satisfactory results have been reported with a number of different reservoir designs; however, the optimal reservoir size and configuration remain controversial. Two groups of five dogs each, undergoing colectomy and PTR with construction of either 5-cm-long or 18-cm-long lateral ileal reservoirs, were studied to compare defecatory patterns, intestinal transit, and reservoir emptying. Three months postoperatively, dogs with long ileal reservoirs demonstrated a higher stool frequency and made more unsuccessful attempts at defecation. Evacuation of viscous polyethylene glycol solution from the long reservoirs was prolonged during the first hour compared with short reservoirs. Two of the five long reservoirs showed mucosal ulcerations on postmortem examination, whereas none were present in any of the short pouches. Increases in stool water content and subsequent reduction of urine volumes as well as a prolongation in oroanal transit times occurred to a similar degree in both groups. It is concluded that short lateral isoperistaltic reservoirs empty more effectively than do long reservoirs.

Animals↗
PubMed1994

Anorectal function.

A review in a historic perspective of the present knowledge of anorectal physiology is presented. The techniques used in the anorectal physiology laboratory are discussed. Application of new sophisticated techniques to anorectal physiology research in recent years continue to improve our knowledge of anorectal function. Anal continence and defecation depend on both the anal sphincter and the rectum. The assessment of patients with functional anorectal diseases should include a more complete physiologic evaluation of the anorectum than used previously.

Anal Canal↗
PubMed1996

Lack of correlation of anorectal manometry with symptoms of chronic childhood constipation and encopresis.

UNLABELLED: Chronic constipation is an extremely common problem in children. Many authors have advocated using anorectal manometric examination during evaluation of chronic childhood constipation and encopresis as a means of developing individualized modes of treatment. PURPOSE: This study was designed to prospectively examine frequency and severity of symptoms of childhood constipation and encopresis and associate these symptoms with anorectal manometric findings. METHODS: Forty-four children with chronic constipation participated in the study. Before performing anorectal manometry, bowel-related symptoms were collected for two consecutive weeks with a computerized voice mail system. Anorectal manometry was performed using a triple lumen catheter attached to a hydraulic manometry infusion system. RESULTS: Frequency of voluntary bowel movements did not correlate with any manometric parameters. Frequency of fecal soiling, age at onset of symptoms, and duration of symptoms were all highly correlated with degree of sphincter spasm during attempted defecation; however, none of these variables correlated with any other manometric parameter. Amount of pain associated with bowel movements correlated with frequency of soiling and was inversely correlated with maximum squeeze pressure but was not correlated with any other manometric parameter. CONCLUSIONS: In children with chronic constipation and encopresis, sphincter spasm demonstrated with anorectal manometry is highly correlated with frequency of fecal soiling, age at onset, and duration of symptoms; however, none of the other commonly measured manometric parameters appear to correlate with symptoms of chronic childhood constipation and encopresis.

Age of Onset↗
PubMed1995

Pudendal neuropathy is not related to physiologic pelvic outlet obstruction.

UNLABELLED: Chronic straining because of pelvic outlet obstruction is hypothesized to cause pudendal neuropathy (PN) by stretch injury. PURPOSE: The aim of this study was to determine any association between PN and pelvic outlet obstruction. METHODS: One hundred forty-seven constipated patients were evaluated by cinedefecography and pudendal nerve terminal motor latency assessment. PN was defined as a latency longer than 2.2 ms. Pelvic outlet obstructive patterns of evacuation included paradoxic contraction, nonrelaxation of the puborectalis muscle, or failure of opening of the anal canal. RESULTS: Median length of constipation including straining during evacuation was eight (range, 1-47) years. Ninety-one (62 percent) subjects had a normal pattern of evacuation, and 56 (38 percent) had an obstructed pattern. Both groups had a similar median age (68 vs. 69 years, respectively; P > 0.05) and same median length of symptoms. Overall incidence of PN was 23.8 percent (10.9 percent unilateral and 12.9 percent bilateral). There was no difference in the incidence of PN between patients with normal evacuation and patients with obstructed evacuation (24.2 percent vs. 23.2 percent, respectively; P > 0.05). Patients with PN had a similar incidence of physiologic pelvic outlet obstruction as did patients without PN. However, median age of patients with PN was higher than those without PN (73 vs. 66 years, respectively; P > 0.05). CONCLUSION: There was a difference in the incidence of PN between normal and obstructed patterns of evacuation. Therefore, the espoused theory that obstructed defecation causes PN appears flawed.

Adolescent↗