Defecography. Results of investigations in 2,816 patients

Pathophysiology and treatment of anterior rectal mucosal prolapse syndrome

BACKGROUND

The study was designed to investigate the clinical presentation and laboratory findings of anterior rectal mucosal prolapse (ARMP) and to assess the results of two therapeutic modalities.

METHODS

Some 162 women with ARMP were assessed clinically and by defaecography and rectoanal manometry before and 1 year after one or two sessions of submucosal sclerotherapy or, in the case of recurrence, after transanal excision of the prolapsing mucosa.

RESULTS

Almost all patients reported a combination of symptoms suggesting obstructive defaecation. At defaecography anterior rectocele and excessive perineal descent at straining were present in 78 and 72 per cent respectively. The size of coexisting anterior rectocele and the extent of perineal descent were significantly related to the duration of the disease (P< 0.001). One or, in the event of recurrence, two sessions of sclerotherapy led to an overall success rate of 51 per cent. Improvement after sclerotherapy was associated with partial recovery of anal tone and improvement of anal sampling and rectal sensation. Failure of sclerotherapy was related to rectocele of larger size (P< 0.001) and a longer perineal descent at straining (P< 0.001) than in patients with a successful outcome. Excision of the prolapsing mucosa resulted in symptomatic improvement in 42 of 47 patients and was associated with significant improvement of the defaecographic and manometric findings.

CONCLUSION

ARMP is usually associated with anterior rectocele and excessive perineal descent. Submucosal sclerotherapy is successful in half of the cases, but only in the presence of a rather small anterior rectocele and short perineal descent. Failures after sclerotherapy can be treated by transanal excision of the prolapsing mucosa.

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.

Internal rectal intussusception seldom develops into total rectal prolapse

PURPOSE

This study was designed to analyze how often internal rectal intussusception develops into total rectal prolapse.

METHODS

Repeated investigations with defecography were performed in 312 patients because of persisting symptoms. In 79 patients who had a rectal intussusception at the first defecography, results of the second defecography and the patients' records were studied.

RESULTS

A total of 38 patients had not undergone any surgical treatment of rectal intussusception or rectal prolapse between the first and second defecographies. One of these patients had a rectal prolapse at the second defecography, and another developed a clinical prolapse after the second defecography.

CONCLUSIONS

The present study demonstrates that the risk of developing a rectal prolapse in patients with rectal intussusception is small. This risk should, therefore, not be used as an indication for surgery.

Role of defecography in predicting clinical outcome of rectocele repair

PURPOSE

The aim of this study was to evaluate the role of defecography in predicting clinical outcome of rectocele repair.

METHODS

Between January 1988 and July 1994, 74 consecutive patients (median age, 54 (range, 35-81) years) with a rectocele and symptoms of obstructed defecation were studied prospectively. After preoperative evaluation by a standardized questionnaire, physical examination, and defecography, a combined transvaginal/transanal rectocele repair was performed. At follow-up, all patients had defecography. Long-term results were qualified by an independent observer after a median follow-up of 58 (range, 14-89) months as "excellent," "good," or "poor."

RESULTS

Rectocele repair was considered excellent in 37 patients and good in 13 patients. Defecography six months after surgery did not show persistent or recurrent rectocele in any of the patients. Size of the rectocele, barium-trapping in the rectocele, internal intussusception, rectal evacuation, and perineal descent did not appear to influence clinical outcome. Radiologic evidence of anismus did not correlate with long-term results of rectocele repair.

CONCLUSIONS

Combined transanal/transvaginal repair of rectocele is an efficient therapy in patients with obstructed defecation. Various defecographic parameters (size of rectocele, internal intussusception, rectal evacuation, perineal descent, radiologic signs of anismus) do not appear to influence clinical outcome of surgery. The main value of defecography is the objective demonstration of rectocele and any associated abnormalities such as an enterocele preoperatively and again in objective assessment of the postoperative results.

Defecography and proctography. Results of 744 patients

PURPOSE

Radiographic imaging of dynamic changes within the pelvic cavity and rectum during evacuation has been recognized as a valuable method of assessment. This study was designed to assess the incidence and clinical significance of defecographic findings in patients with possible evacuation disorders.

MATERIALS AND METHODS

All defecographic studies were reviewed by a single colorectal surgeon familiar with patients' histories and physical findings.

RESULTS

Between July 1988 and July 1995, 744 patients (566 females and 178 males) with a mean age of 63.5 (range, 12-95) years had defecographic and proctographic examination. Four hundred forty-six (60 percent) patients were diagnosed who complained of constipation, 123 (16.5 percent) of fecal incontinence, 42 (5.6 percent) of rectal prolapse, 82 (11 percent) of rectal pain, and 51 (6.9 percent) had a combination of more than one of these diagnoses. Although 93 (12.5 percent) of these evaluations were considered normal, 61 (8 percent) revealed rectal prolapse, 191 (25.7 percent) rectocele, 82 (11 percent) sigmoidocele, and 94 (12.6 percent) intussusception; in 223 (30 percent) patients, a combination of these findings was noted. Patients with paradoxical puborectalis contraction had an extremely high frequency of constipation compared with other symptoms (P < 0.0001).

CONCLUSIONS

Defecography can reveal abnormalities in the majority of patients with evacuatory disorders. There was a high incidence of rectocele, sigmoidocele, and intussusception. Care must be taken not to treat patients strictly based on radiographic findings.

Continence is improved after the Ripstein rectopexy. Different mechanizms in rectal prolapse and rectal intussusception?

PURPOSE

This study was undertaken to evaluate anal manometric changes after Ripstein's operation for rectal prolapse and rectal intussusception and to study the clinical outcome following the operation, with special reference to anal incontinence.

METHODS

Forty-two patients with rectal prolapse or rectal intussusception were subjected to anorectal manometry preoperatively and seven days and six months postoperatively. A detailed history was obtained from each patient preoperatively and six months postoperatively.

RESULTS

Preoperatively, patients with rectal intussusception had higher maximum resting pressure (MRP) (52+/- 23 mmHg) than patients with rectal prolapse (34 +/- 20 mmHg; P < 0.01). In the group of patients with rectal prolapse, there was a postoperative increase in MRP after six months (P < 0.001) but not after seven days. Maximum squeeze pressure (MSP) did not increase. Neither MRP nor MSP increased postoperatively in patients with internal rectal procidentia. Continence was improved postoperatively both in patients with rectal prolapse (P < 0.01) and rectal intussusception (P < 0.01). There was no postoperative increase in rectal emptying difficulties.

CONCLUSION

Ripstein's operation often improved anal continence in patients with rectal prolapse and rectal intussusception. This improvement was accompanied by increased MRP in patients with rectal prolapse, indicating recovery of internal anal sphincter function. No postoperative increase in MRP was found in patinets with rectal intussusception. This suggests an alternate mechanism of improvement in patients with rectal intussusception.

Simultaneous defecography and peritoneography in defecation disorders

A number of physiologic and radiologic investigations are used in investigating defecation disorders. Defecography is one important part of these investigations. However, a correct diagnosis of an enterocele is sometimes difficult despite use of contrast media in the rectum, vagina, and small bowel.

PURPOSE

This study was undertaken to ascertain if it was technically possible to perform simultaneous defecography and peritoneography in an effort to improve the diagnostic possibilities in patients with defecation disorders.

METHODS

Twelve patients with defecation disorders and an unexplained widening of the rectovaginal space at defecography were investigated. Contrast medium was introduced intraperitoneally, after which conventional defecography was performed.

RESULTS

All investigations were carried out without complications and demonstrated the peritoneal outline in all patients. Simultaneous defecography and peritoneography differentiated between an enterocele and a pathologically deep pouch of Douglas--a peritoneocele. Three types of peritoneocele were visualized: vaginal peritoneocele, septal peritoneocele, and rectal peritoneocele with or without enterocele. Combinations of the three types were also found. Eight of the 12 patients had rectal intussusception or rectal prolapse. All of these eight patients had a rectal peritoneocele.

CONCLUSIONS

Simultaneous defecography and peritoneography can be performed without technical difficulties or complications. Peritoneal outlines and pouches can, therefore, be studied directly during the act of defecation. An unexplained widening of the rectovaginal space at defecography can be clarified as a peritoneocele, with or without an enterocele. Peritoneocele can be of three different types: rectal, septal, or vaginal.

Results of rectocele repair. A prospective study

PURPOSE

This study was designed to evaluate the results of rectocele repair and parameters that might be useful in selecting patients for this operation.

METHODS

Twenty-five patients with symptom-giving rectoceles were prospectively evaluated with a standardized questionnaire, physical examination, defecography, colon transit studies, anorectal manometry, and electrophysiology. Patients underwent posterior colporrhaphy and perineorrhaphy. They were followed postoperatively (mean, 1.0 year) with the same questionnaire, physical examination, defecography, anorectal manometry, and electrophysiology.

RESULTS

Constipation had improved postoperatively in 21 of 24 constipated patients (88 percent). At postoperative follow-up 13 patients (52 percent) had no constipation symptoms, 8 (32 percent) had occasional symptoms, and 4 (16 percent) had symptoms more than once per week. Four patients with rectocele at preoperative defecography, but not at physical examination, had favorable outcomes following surgery. The majority of patients not using vaginal digitalization preoperatively had improved with respect to constipation. All patients with pathologic transit studies had various degrees of constipation postoperatively. Constipation was not improved in two of five patients with preoperative paradoxic sphincter reaction.

CONCLUSIONS

Rectocele is one cause of constipation that can be treated with good results. Preoperative use of vaginal digitalization is not mandatory for a good postoperative result. Defecography is an important complement to physical examination. Patients with pathologic transit study might have a less favorable outcome of rectocele repair with respect to constipation. More studies about the significance of paradoxic sphincter reaction in these patients are indicated.