The reproducibility of measuring the anorectal angle in defecography

The influence of defaecating proctograms on clinical decision-making in pelvic floor disorders

AIM

Defaecating proctogram (DP) studies have become an integral part of the evaluation of patients with pelvic floor disorders. However, their impact on treatment decision-making remains unclear. The aim of this study was to assess the concordance of decision-making by colorectal surgeons and the role of the DP in this process.

METHOD

Four colorectal surgeons were presented with online surveys containing the complete history, examination and investigations of 106 de-identified pelvic floor patients who had received one of three treatment options: physiotherapy only, anterior Delorme's procedure or anterior mesh rectopexy. The survey assessed the management decisions made by each of the surgeons for the three treatments both before and after the addition of the DP to the diagnostic work-up.

RESULTS

After the addition of the DP results; treatment choice changed in 219 (52%) of 424 surgical decisions and interrater agreement improved significantly from κ = 0.26 to κ = 0.39. Three of the four surgeons reported a significant increase in confidence. Agreement with the actual treatments patients received increased from κ = 0.21 to κ = 0.28. Intra-anal rectal prolapse on DP was a significant predictor of a decision to perform anterior mesh rectopexy.

CONCLUSION

The DP improves interclinician agreement in the management of pelvic floor disorders and enhances the confidence in treatment decisions. Intra-anal rectal prolapse was the most influential DP parameter in treatment decision-making.

Imaging modalities for the detection of posterior pelvic floor disorders in women with obstructed defaecation syndrome

BACKGROUND

Obstructed defaecation syndrome (ODS) is difficulty in evacuating stools, requiring straining efforts at defaecation, having the sensation of incomplete evacuation, or the need to manually assist defaecation. This is due to a physical blockage of the faecal stream during defaecation attempts, caused by rectocele, enterocele, intussusception, anismus or pelvic floor descent. Evacuation proctography (EP) is the most common imaging technique for diagnosis of posterior pelvic floor disorders. It has been regarded as the reference standard because of extensive experience, although it has been proven not to have perfect accuracy. Moreover, EP is invasive, embarrassing and uses ionising radiation. Alternative imaging techniques addressing these issues have been developed and assessed for their accuracy. Because of varying results, leading to a lack of consensus, a systematic review and meta-analysis of the literature are required.

OBJECTIVES

To determine the diagnostic test accuracy of EP, dynamic magnetic resonance imaging (MRI) and pelvic floor ultrasound for the detection of posterior pelvic floor disorders in women with ODS, using latent class analysis in the absence of a reference standard, and to assess whether MRI or ultrasound could replace EP. The secondary objective was to investigate differences in diagnostic test accuracy in relation to the use of rectal contrast, evacuation phase, patient position and cut-off values, which could influence test outcome.

SEARCH METHODS

We ran an electronic search on 18 December 2019 in the Cochrane Library, MEDLINE, Embase, SCI, CINAHL and CPCI. Reference list, Google scholar. We also searched WHO ICTRP and clinicaltrials.gov for eligible articles. Two review authors conducted title and abstract screening and full-text assessment, resolving disagreements with a third review author.

SELECTION CRITERIA

Diagnostic test accuracy and cohort studies were eligible for inclusion if they evaluated the test accuracy of EP, and MRI or pelvic floor ultrasound, or both, for the detection of posterior pelvic floor disorders in women with ODS. We excluded case-control studies. If studies partially met the inclusion criteria, we contacted the authors for additional information.

DATA COLLECTION AND ANALYSIS

Two review authors performed data extraction, including study characteristics, 'Risk-of-bias' assessment, sources of heterogeneity and test accuracy results. We excluded studies if test accuracy data could not be retrieved despite all efforts. We performed meta-analysis using Bayesian hierarchical latent class analysis. For the index test to qualify as a replacement test for EP, both sensitivity and specificity should be similar or higher than the historic reference standard (EP), and for a triage test either specificity or sensitivity should be similar or higher. We conducted heterogeneity analysis assessing the effect of different test conditions on test accuracy. We ran sensitivity analyses by excluding studies with high risk of bias, with concerns about applicability, or those published before 2010. We assessed the overall quality of evidence (QoE) according to GRADE.

MAIN RESULTS

Thirty-nine studies covering 2483 participants were included into the meta-analyses. We produced pooled estimates of sensitivity and specificity for all index tests for each target condition. Findings of the sensitivity analyses were consistent with the main analysis. Sensitivity of EP for diagnosis of rectocele was 98% (credible interval (CrI)94%-99%), enterocele 91%(CrI 83%-97%), intussusception 89%(CrI 79%-96%) and pelvic floor descent 98%(CrI 93%-100%); specificity for enterocele was 96%(CrI 93%-99%), intussusception 92%(CrI 86%-97%) and anismus 97%(CrI 94%-99%), all with high QoE. Moderate to low QoE showed a sensitivity for anismus of 80%(CrI 63%-94%), and specificity for rectocele of 78%(CrI 63%-90%) and pelvic floor descent 83%(CrI 59%-96%). Specificity of MRI for diagnosis of rectocele was 90% (CrI 79%-97%), enterocele 99% (CrI 96%-100%) and intussusception 97% (CrI 88%-100%), meeting the criteria for a triage test with high QoE. MRI did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of MRI performed with evacuation phase was higher than without for rectocele (94%, CrI 87%-98%) versus 65%, CrI 52% to 89%, and enterocele (87%, CrI 74%-95% versus 62%, CrI 51%-88%), and sensitivity of MRI without evacuation phase was significantly lower than EP. Specificity of transperineal ultrasound (TPUS) for diagnosis of rectocele was 89% (CrI 81%-96%), enterocele 98% (CrI 95%-100%) and intussusception 96% (CrI 91%-99%); sensitivity for anismus was 92% (CrI 72%-98%), meeting the criteria for a triage test with high QoE. TPUS did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of TPUS performed with rectal contrast was not significantly higher than without for rectocele(92%, CrI 69%-99% versus 81%, CrI 58%-95%), enterocele (90%, CrI 71%-99% versus 67%, CrI 51%-90%) and intussusception (90%, CrI 69%-98% versus 61%, CrI 51%-86%), and was lower than EP. Specificity of endovaginal ultrasound (EVUS) for diagnosis of rectocele was 76% (CrI 54%-93%), enterocele 97% (CrI 80%-99%) and intussusception 93% (CrI 72%-99%); sensitivity for anismus was 84% (CrI 59%-96%), meeting the criteria for a triage test with very low to moderate QoE. EVUS did not meet the criteria to replace EP. Specificity of dynamic anal endosonography (DAE) for diagnosis of rectocele was 88% (CrI 62%-99%), enterocele 97% (CrI 75%-100%) and intussusception 93% (CrI 65%-99%), meeting the criteria for a triage test with very low to moderate QoE. DAE did not meet the criteria to replace EP. Echodefaecography (EDF) had a sensitivity of 89% (CrI 65%-98%) and specificity of 92% (CrI 72%-99%) for intussusception, meeting the criteria to replace EP but with very low QoE. Specificity of EDF for diagnosis of rectocele was 89% (CrI 60%-99%) and for enterocele 97% (CrI 87%-100%); sensitivity for anismus was 87% (CrI 72%-96%), meeting the criteria for a triage test with low to very low QoE.

AUTHORS' CONCLUSIONS

In a population of women with symptoms of ODS, none of the imaging techniques met the criteria to replace EP. MRI and TPUS met the criteria of a triage test, as a positive test confirms diagnosis of rectocele, enterocele and intussusception, and a negative test rules out diagnosis of anismus. An evacuation phase increased sensitivity of MRI. Rectal contrast did not increase sensitivity of TPUS. QoE of EVUS, DAE and EDF was too low to draw conclusions. More well-designed studies are required to define their role in the diagnostic pathway of ODS.

Defecography

Defecography, a dynamic imaging modality, plays an important role in the diagnosis of functional and morphologic abnormalities of the anorectal region. We have here summarized the principle and techniques as well as observations of defecography, with special emphasis on morphologic measurements, clinical relevance, and limitations. The application of MR imaging in examination of anorectal function has also been addressed.

The value of fluoroscopic defecography in the diagnostic and therapeutic management of defecation disorders in children

BACKGROUND

Defecography is a study to assess anorectal function during evacuation.

OBJECTIVE

To investigate the value of fluoroscopic defecography in directing diagnostic and therapeutic management in children with defecation disorders.

MATERIALS AND METHODS

We reviewed all fluoroscopic defecography studies performed (2003-2009) in children with defecation problems and normal anorectal motility studies. Results were classified into three groups: (1) normal pelvic floor function; (2) pelvic floor dyssynergia, including incomplete relaxation of pelvic musculature, inconsistent change in anorectal angle and incomplete voluntary evacuation; (3) structural abnormality, including excessive pelvic floor descent with an intra-rectal intussusception, rectocele or rectal prolapse.

RESULTS

We included 18 patients (13 boys, median age 9.1 years). Indication for fluoroscopic defecography was chronic constipation in 56%, fecal incontinence in 22% and rectal prolapse in 22%. Defecography showed pelvic floor dyssynergia in 9 children (50%), a structural abnormality in 4 (22%) and normal pelvic floor function in 5 (28%). In 12 children (67%) the outcome of fluoroscopic defecography directly influenced therapeutic management. After defecography 4 children (22%) were referred for anorectal biofeedback treatment, 4 children (22%) for surgery, 2 children (11%) for additional MR defecography, and 1 child to the psychology department, and medication was changed in 1 child. In 6 children (33%) the result did not change the management. In 9 children (75%) the change of management was successful.

CONCLUSIONS

Fluoroscopic defecography can be a useful tool in understanding the pathophysiology and it may provide information that impacts management of children with refractory defecation disorders.

High-resolution anorectal manometry and dynamic pelvic magnetic resonance imaging are complementary technologies

BACKGROUND AND AIM

Dynamic pelvic magnetic resonance imaging (DP-MRI) offers a comprehensive evaluation of pelvic organ structure in addition to functional information regarding evacuation. Opportunity to apply this technology can be limited due to regional lack of availability. Ideally, clues from standard anorectal testing could predict abnormalities on DP-MRI, leading to its efficient use. The aim of this study is to determine whether high-resolution anorectal manometry (HR-ARM) correlates with findings on DP-MRI.

METHODS

This is a retrospective study of HR-ARM performed on patients with constipation who also underwent DP-MRI. Studies were reviewed for significant findings including posterior pelvic organ prolapse, rectocele > 3 cm, rectal intussusception, and anorectal angle. Statistical analysis was performed using Pearson's correlation coefficient, Student's t-test, and Fisher's exact test.

RESULTS

Twenty-three patients undergoing HR-ARM (age range 25-78) also underwent DP-MRI. All were female; 76% were Caucasian. Twenty had significant structural findings: small pelvic prolapse (n = 2), moderate pelvic prolapse (n = 10), large pelvic prolapse (n = 9), rectocele (n = 8), or rectal intussusception (n = 3). Only intrarectal pressure on HR-ARM weakly correlated with size of rectocele (r = 0.46; P = 0.03) and degree of pelvic organ prolapse (r = 0.48; P = 0.02). The remainder of the HR-ARM parameters did not significantly correlate with DP-MRI findings. Patients with dyssynergy were not more likely to have rectoceles > 3 cm (44.4% versus 35.7%; P = 0.5) or large prolapses (44.4% versus 50%, P = 1.0), compared with those without dyssynergy, on HR-ARM.

CONCLUSION

We were unable to find a correlation between HR-ARM findings and structural pelvic defects on DP-MRI. Therefore, these two technologies provide complementary information in the evaluation of defecatory dysfunction.

Comparison between dynamic cystocolpoproctography and dynamic pelvic floor MRI: pros and cons: which is the "functional" examination for anorectal and pelvic floor dysfunction?

"Functional" imaging of anorectal and pelvic floor dysfunction has assumed an important role in the diagnosis and management of these disorders. Although defecography has been widely practiced for decades to evaluate the dynamics of rectal emptying, debate concerning its clinical relevance, how it should be done and interpreted continues. Due to the recognition of the association of defecatory disorders with pelvic organ prolapse in women, the need to evaluate the pelvic floor as a unit has arisen. To meet this need, defecography has been extended to include not only evaluation of defecation disorders but also the rest of the pelvic floor by opacifying the small bowel, vagina, and the urinary bladder. The term "dynamic cystocolpoproctography" (DCP) has been appropriately applied to this examination. Rectal emptying performed with DCP provides the maximum stress to the pelvic floor resulting in complete levator ani relaxation. In addition to diagnosing defecatory disorders, this method of examination demonstrates maximum pelvic organ descent and provides organ-specific quantification of organ prolapse, information that is only inferred by means of physical examination. It has been found to be of clinical value in patients with defecation disorders and the diagnosis of associated prolapse in other compartments that are frequently unrecognized by history taking and the limitations of physical examination. Pelvic floor anatomy is complex and DCP does not show the anatomical details pelvic magnetic resonance imaging (MRI) provides. Technical advances allowing acquisition of dynamic rapid MRI sequences has been applied to pelvic floor imaging. Early reports have shown that pelvic MRI may be a useful tool in pre-operative planning of these disorders and may lead to a change in surgical therapy. Predictions of hypothetical increase cancer incidence and deaths in patients exposed to radiation, the emergence of pelvic floor MRI in addition to questions relating to the clinical significance of DCP findings have added to these controversies. This review analyses the pros and cons between DCP and dynamic pelvic floor MRI, addresses imaging and interpretive controversies, and their relevance to clinical management.

MR imaging of the pelvic floor: defecography

Defecography by magnetic resonance (MR) imaging makes it possible to view the multiple compartments of the pelvic floor at one examination, with high-resolution images at rest and dynamic images, providing accurate evaluation of the morphology and function of the anorectal and pelvic organs and muscles, involved in pelvic floor dynamics. MR imaging of the pelvic floor identifies the diseases affecting the evacuation mechanism, providing information essential for surgical planning and choice of treatment approach. This article focuses on the MR details of the pelvic floor anatomy and the most commonly observed anatomic and functional abnormalities.

Lumbosacral plexus injury following vaginal delivery with epidural analgesia -A case report-

A 26 year old, healthy, 41 week primiparous woman received a patient-controlled epidural analgesia (PCEA) and experienced paraplegia 11 hours later after a vaginal delivery. This was thought to be the result of complications from PCEA but there was no specific abnormality on magnetic resonance imaging (MRI) of the lumbosacral spine. On an electromyography (EMG) study performed 15 days following delivery, signs of tibial neuropathy were present and peripheral nerve injury during vaginal delivery was suspected. Motor weakness and hypoesthesia of both lower extremities improved rapidly, but a decrease in the desire to urinate or defecate, followed by urinary incontinence and constipation persisted, We suspected the sacral plexus had been severely damaged during vaginal delivery. Seven months later, the patient's conditions improved but had not fully recovered.

An analysis of factors associated with increased perineal descent in women

Purpose

Treatment of descending perineal syndrome is focused on personal etiology and on improving symptoms. However, the etiology of increased perineal descent (PD) is unclear. Therefore, the aim of the present study was to evaluate factors associated with increased resting and dynamic PD in women.

Methods

From January 2004 to August 2010, defecographic findings in 201 female patients were reviewed retrospectively. Patient's age, surgical history, manometric results and defecographic findings were compared with resting and dynamic PD.

Results

Age (P < 0.01), number of vaginal deliveries (P < 0.01) and resting anorectal angle (P < 0.01) were correlated with increased resting PD. Also, findings of rectoceles (P < 0.05) and intussusceptions (P < 0.05) were significantly correlated with increased resting PD. On the other hand, increased dynamic PD was correlated with age (P < 0.05), resting anal pressure (P < 0.01) and sigmoidoceles (P < 0.05). No significant correlation existed between non-relaxing puborectalis, history of pelvic surgery and increased PD. Also, no significant differences in PD according to the symptoms were observed.

Conclusion

Increased number of vaginal deliveries and increased resting rectoanal angle are associated with increased resting PD whereas increased resting anal pressure is correlated with increased dynamic PD. Older age correlates with both resting and dynamic PD. Defecographic findings, such as rectoceles and intussusceptions, are associated with resting PD, and sigmoidoceles correlated with dynamic PD. These results can serve as foundational research for understanding the pathophysiology and causes of increasing PD in women better and for finding a fundamental method of treatment.

Automatic estimation of pelvic organ anatomical references

Pelvic floor diseases cover pathologies of which physiopathology is not well understood. 2D sagittal MRI sequences used in the clinical assessment allow to visualize the dynamic behavior of the main organs involved (bladder, uterus-vagina and rectum). Clinicians use anatomical landmarks and measurements related to the pelvic organs in their pathology assessment. Usually, those tasks are performed manually which results in being both tedious and subject to operator dependency. A methodology is proposed to attempt a quantitative and objective characterization of the organ behaviors under abdominal strain condition. This approach automatically assesses the organ movements, through the estimation of characteristic angles (anorectal angle, uterovaginal angle, bladder inclination), and the tracking of anatomically significant points (anorectal angle vertex, uterovaginal angle vertex, bladder neck). From a multi-subject analysis, pathological organs have been distinguished from healthy ones, which shows the relevance of the computed features. In addition, a stability analysis has shown the soundness of the approach.

Correlations of anatomical parameters in dynamic pelvic CT and conventional defecography for patients with rectal prolapse

PURPOSE

To evaluate the correlations of anatomical parameters between dynamic pelvic CT (D-PCT) and conventional defecography (CD) for patients with rectal prolapse.

MATERIAL AND METHODS

Anatomical parameters in multislice CT scanning of the pelvis performed at rest and during simulated defecation (D-PCT) were studied with those of CD to evaluate the correlations in both methods for 10 patients with rectal prolapse.

RESULT

The correlation coefficients of the pubococcygeal line and the pubosacral line were r=0.6 and r=0.8 respectively. The length from anal verge to pubococcygeal line and to the pubosacral line showed a good correlation of r=0.7. The length of puborectal muscle showed a good correlation of r=0.8. Anorectal angle was significantly well correlated between two methods (r=0.9, p<0.05). The lengths of anococcygeal length and anosacral length showed a good correlation.

CONCLUSION

The anatomical parameters measured by D-PCT were well correlated with those by CD. D-PCT might be an alternative tool for anatomical evaluation of the anorectal region in patients with rectal prolapse.

Prospective Assessment of Interobserver Agreement for Defecography in Fecal Incontinence

OBJECTIVE

The primary aim of our study was to determine the interobserver agreement of defecography in diagnosing enterocele, anterior rectocele, intussusception, and anismus in fecal-incontinent patients. The subsidiary aim was to evaluate the influence of level of experience on interpreting defecography.

SUBJECTS AND METHODS

Defecography was performed in 105 consecutive fecal-incontinent patients. Observers were classified by level of experience and their findings were compared with the findings of an expert radiologist. The quality of the expert radiologist's findings was evaluated by an intraobserver agreement procedure.

RESULTS

Intraobserver agreement was good to very good except for anismus: incomplete evacuation after 30 sec (kappa, 0.55) and puborectalis impression (kappa, 0.54). Interobserver agreement for enterocele and rectocele was good (kappa, 0.66 for both) and for intussusception, fair (kappa, 0.29). Interobserver agreement for anismus: incomplete evacuation after 30 sec was moderate (kappa, 0.47), and for anismus: puborectalis impression was fair (kappa, 0.24). Agreement in grading of enterocele and rectocele was good (kappa, 0.64 and 0.72, respectively) and for intussusception, fair (kappa, 0.39). Agreement separated by experience level was very good for rectocele (kappa, 0.83) and grading of rectoceles (kappa, 0.83) and moderate for intussusception (kappa, 0.44) at the most experienced level. For enterocele and grading, experience level did not influence the reproducibility.

CONCLUSION

Reproducibility for enterocele, anterior rectocele, and severity grading is good, but for intussusception is fair to moderate. For anismus, the diagnosis of incomplete evacuation after 30 sec is more reproducible than puborectalis impression. The level of experience seems to play a role in diagnosing anterior rectocele and its grading and in diagnosing intussusception.

Review article: Recent trends in diagnosis and treatment of faecal incontinence

The inability to control bowel discharge is not only common but extremely distressing. It has a negative impact on a patient's lifestyle, leads to a loss of self-esteem, social isolation and a diminished quality of life. Faecal incontinence is often due to multiple pathogenic mechanisms and rarely due to a single factor. Normal continence to stool is maintained by the structural and functional integrity of the anorectal unit. Consequently, disruption of the normal anatomy or physiology of the anorectal unit leads to faecal incontinence. Currently, several diagnostic tests are available that can provide an insight regarding the pathophysiology of faecal incontinence and thereby guide management. The treatment of faecal incontinence includes medical, surgical or behavioural approaches. Today, by using logical approach to management, it is possible to improve symptoms and bowel function in many of these patients.

Predictive value of impaired evacuation at proctography in diagnosing anismus

OBJECTIVE

We aimed to determine the positive predictive value of impaired evacuation during evacuation proctography for the subsequent diagnosis of anismus.

SUBJECTS AND METHODS

Thirty-one adults with signs of impaired evacuation (defined as the inability to evacuate two thirds of a 120 mL contrast enema within 30 sec) during evacuation proctography underwent subsequent anorectal physiologic testing for anismus. A physiologic diagnosis of anismus was based on a typical clinical history of the condition combined with impaired rectal balloon expulsion or abnormal surface electromyogram.

RESULTS

Twenty-eight (90%) of the 31 patients with impaired proctographic evacuation were found to have anismus at subsequent physiologic testing. Among the 28 were all 10 patients who evacuated no contrast medium and all 11 patients with inadequate pelvic floor descent, giving evacuation proctography a positive predictive value of 90% for the diagnosis of anismus. A prominent puborectal impression was seen in only three subjects during proctography, one of whom subsequently showed no physiologic sign of anismus.

CONCLUSION

Impaired evacuation during evacuation proctography is highly predictive for diagnosis of anismus.

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.

Endosonography for assessment of anorectal changes in patients with fecal incontinence

Our aim was to evaluate the anorectal changes in patients with fecal incontinence by using different endoultrasound techniques. Eighteen females with fecal incontinence and 14 healthy controls (females) were examined. Rigid linear transducer and 10 MHz radial scanning miniprobe were used. Statistically significant difference was found in the mean percentage of decreasing of the anorectal angle during contraction between healthy subjects (21.4%) and incontinent patients (7.5%). The mean percentage of shortening of the puborectal muscle length during squeezing was significantly lower in patients (9.6%) than in controls (17.9%). By means of miniprobe the anal sphincter defects were clearly demonstrated. Endosonography with a radial scanning miniprobe and rigid linear transducer ensures complex morphological and functional assessment of the anorectal region.

Inter-observer variability in the reporting of dynamic evacuation proctography

OBJECTIVE

To determine the degree of inter-observer variability between two reporters of dynamic evacuation proctography (DEP).

PATIENTS AND METHODS

The videotapes of 136 patients who had undergone the investigation of DEP in a 1-year period were retrospectively and independently reported by two of the authors. The authors recorded the presence or absence of an anterior rectocoele (as well as size-small, medium or large), an intussusception, a rectal prolapse and any degree of non-relaxing puborectalis syndrome (NRPS).

RESULTS

The results were analysed using the κ statistic. I.W.I. reported 18% of the proctograms as normal. S.G.S. reported 26% of the proctograms as normal. κ scores for agreement on the presence or absence of rectal prolapses, NRPS, intussusception and anterior rectocoeles between the two reporters were 0.79, 0.70, 0.54 and 0.82, respectively.

CONCLUSION

Usefulness of an investigation is dependent upon its reproducibility and hence on the degree of inter-observer variability in its reporting. Our study shows that DEP is a useful investigation for delineating the mechanics of the pelvic floor and that consistency of reporting in our Department is good.

Intraobserver and interobserver measurements of the anorectal angle and perineal descent in defecography

PURPOSE

Anorectal angle and perineal descent can be measured either by drawing a line defined by the impression of the puborectalis muscle and the tangential of the posterior rectal wall (Method A) or by drawing a straight line at the level of the posterior rectal wall parallel to the central longitudinal axis of the rectum (Method B). The aim of this study was to assess the reproducibility of measuring anorectal angle and perineal descent by two different methods according to intraobserver and interobserver measurement and to evaluate which method yields more consistent results.

METHODS

Five physicians who have had an average of 1.3 years (range, 6 months to 1.5 years) experience in defecographic measurement drew both lines on 63 randomly selected defecographic films and measured anorectal angle and perineal descent by the two methods. The defecographic parameters were measured twice by each observer during a three-week interval. To avoid potential bias, one physician who did not participate in either measurement of perineal descent or anorectal angle performed all data collection. Intraobserver and interobserver agreement was quantified using Shrout and Fleiss intraclass correlation coefficients.

RESULTS

The mean and range of intraclass correlation coefficients for intraobserver agreement of measuring anorectal angle and perineal descent by Method A were 0.71 (0.6-0.78) and 0.89 (0.74-0.97), respectively, whereas with Method B the coefficients were 0.81 (0.73-0.89) and 0.93 (0.89-0.99), respectively. Regarding the interobserver agreement of the five observers, the mean coefficients for measurement of both anorectal angle and perineal descent by both methods showed similar agreement levels (0.88 and 0.98 by Method A and 0.89 and 0.97 by Method B). The mean (+/- standard deviation) values of anorectal angle and perineal descent found by Method B were significantly larger than those found by Method A (103.3 degrees +/- 19.6 and 6.56+/-3.20 cm and 91.1 degrees +/- 25.6 and 5.64+/-3.42 cm, respectively; P<0.001).

CONCLUSION

Intraobserver and interobserver intraclass correlation coefficients of anorectal angle and perineal descent, which were measured by both methods, were more than 0.60, indicating that both methods are reliable and consistent for measurement of anorectal angle and perineal descent. However, centers should consistently use the same line for measurement of anorectal angle and perineal descent because of the statistically significant differences between the two methods and the possibility of inconsistent results.

Tomographical anatomy of the pelvis, pelvic floor, and related structures

The sectional anatomy of the pelvic floor was studied in plastinated sections of adult pelves by computed tomography and by magnetic resonance imaging. In sectional anatomy, the levator ani is composed of three portions that can be clearly distinguished by their planes of cleavage and by the course of their fiber bundles. No muscular connections are found between the levator ani portions and the pelvic organs. The fascia of the levator ani in always interposed between the muscle and the pelvic organs. The sectional anatomy of the sphincter ani externus reveals a subdivision into a subcutaneous and a deep portion. Although the puborectalis portion of the levator ani and the deep portion of the sphincter ani externus are more or less continuous, in sectional anatomy they can be distinguished due to their different origins and attachments.

Imaging of anorectal disease

BACKGROUND

Over the past two decades developments in imaging have changed the assessment of patients with anorectal disease.

METHODS

The literature on imaging techniques for anorectal diseases was reviewed over the period 1980-1999.

RESULTS

For the staging of primary rectal tumours, phased array magnetic resonance imaging (MRI) may be regarded as the most appropriate single technique. The combination of endosonography or endoluminal MRI with ultrasonography or spiral computed tomography yields similar results. All techniques have limitations both for local staging and in the assessment of distant metastases. MRI or positron emission tomography is preferable for tumour recurrence. For perianal fistula, high-resolution MRI (phased array or endoluminal) is the technique of choice. For constipation, defaecography is the preferred technique, nowadays with emphasis on functional information. The role of magnetic resonance defaecography is currently being evaluated. For faecal incontinence, endosonography and endoluminal MRI give similar results in detecting sphincter defects; endoluminal MRI has the advantage of detecting external sphincter atrophy.

CONCLUSION

High-resolution MRI, endosonography and defaecography are currently the optimal imaging techniques for anorectal disease.

Evacuation proctography: a prospective study of diagnostic and therapeutic effects

PURPOSE

To determine the diagnostic and therapeutic effects of evacuation proctography.

MATERIALS AND METHODS

Forty-seven referring clinicians completed preevacuation proctography questionnaires for 50 patients, detailing diagnoses, confidence in these, intended management, and what they hoped to learn. After evacuation proctography, the radiology report was returned with a second questionnaire asking the diagnosis in the light of evacuation proctographic findings, their confidence, and what they had learned. Clinicians quantified management contribution and indicated how useful they found evacuation proctography in general. Results from pre- and post-evacuation proctography questionnaires were compared to determine the diagnostic and therapeutic effects.

RESULTS

Diagnostic confidence rose significantly after evacuation proctography (mean, 7.0 before evacuation proctography vs 8.4 after evacuation proctography; P < .001). Lead diagnosis changed in nine (18%) patients. Intended surgical management became nonsurgical after evacuation proctography in seven (14%) patients, and intended nonsurgical therapy became surgical in two (4%). Surgery remained likely in 15 patients, but its nature changed in five (10%). Five (10%) clinicians stated that evacuation proctographic findings resolved diagnostic conflict, and nine (18%) found that evacuation proctographic findings revealed unsuspected diagnoses. Clinicians found evacuation proctography of major benefit in 20 (40%) cases studied and of moderate benefit in 20 (40%). In general, 20 (43%) clinicians found evacuation proctography very useful and 24 (51%) found it moderately useful.

CONCLUSION

Evacuation proctography has a substantial diagnostic and therapeutic effect and is of considerable benefit to referring clinicians.

AGA technical review on anorectal testing techniques

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. Following external review, the paper was approved by the committee on May 17, 1998.

Tomographical anatomy of the pelvis, pelvic floor, and related structures

The sectional anatomy of the pelvic floor was studied in plastinated sections of adult pelves by computed tomography and by magnetic resonance imaging. In sectional anatomy, the levator ani is composed of three portions that can be clearly distinguished by their planes of cleavage and by the course of their fiber bundles. No muscular connections are found between the levator ani portions and the pelvic organs. The fascia of the levator ani in always interposed between the muscle and the pelvic organs. The sectional anatomy of the sphincter ani externus reveals a subdivision into a subcutaneous and a deep portion. Although the puborectalis portion of the levator ani and the deep portion of the sphincter ani externus are more or less continuous, in sectional anatomy they can be distinguished due to their different origins and attachments.

Anismus: fact or fiction?

PURPOSE

Although anismus has been considered to be the principal cause of anorectal outlet obstruction, it is doubtful whether contraction of the puborectalis muscle during straining is paradoxical. The present study was conducted to answer this question.

METHODS

During the first part of the study, we retrospectively reviewed 121 patients with constipation and/or obstructed defecation (male:female, 10/111; median age, 51 years). All of these patients underwent electromyography (EMG) of the pelvic floor and the balloon expulsion test (BET) in the left lateral position. Evacuation proctography was performed in all of these patients in the sitting position. Both the posterior anorectal angle and the central anorectal angle were measured. EMG and BET were also performed in ten controls (male:female, 4/6; median age, 47). In 147 patients with fecal incontinence (male:female, 24/123; median age, 58) only EMG activity was recorded. Criteria for anismus during straining were increase or insufficient (<20 percent) decrease of EMG activity, failure to expel an air-filled balloon on BET, and decrease or insufficient (<5 percent) increase of anorectal angle on evacuation proctography. Between June 1994 and March 1995, we conducted a second prospective study in a consecutive series of 49 patients with constipation and/or obstructed defecation and 28 patients with fecal incontinence. Both groups were compared with 19 control subjects. In this study, all three tests were performed. EMG and BET were performed both in the left lateral position and in the sitting position.

RESULTS

The retrospective study was undertaken by comparing the constipated patients with the incontinent patients and the controls, and the anismus detected by EMG was found in, respectively, 60, 46, and 60 percent. Failure to expel the air-filled balloon was observed in 80 constipated patients (66 percent) and in 9 control subjects (90 percent). Based on posterior anorectal angle and central anorectal angle measurements, anismus was diagnosed in, respectively, 21 and 35 percent of constipated patients. In the prospective study, none of the tests showed significant differences regarding the prevalence of anismus between the two subgroups of patients and the control subjects. The prevalence of anismus only differed between constipated and incontinent patients when the diagnosis was based on BET in the sitting position (67 vs. 32 percent; P < 0.005). Our study shows that contraction of the puborectalis muscle during straining is not exclusively found in patients with constipation and/or obstructed defecation. The three tests most commonly used for the diagnosis of anismus showed an extremely poor agreement.

CONCLUSION

Based on these findings, we doubt the clinical significance of anismus.

Interobserver agreement in defecography

PURPOSE

This study was designed to test the reproducibility of the diagnostic assessment of defecographies in patients with a suspected disorder of defecation.

METHODS

To evaluate interobserver agreement, 100 defecographic series of patients with complaints suggesting a disordered defecation were evaluated independently by three observers with a standardized questionnaire. After six weeks, a random sample of 35 of 100 defecographies was evaluated a second time with clinical data provided (history, proctologic examination). To evaluate whether the position of residual volume in the rectum would affect agreement, patients with substantial retention either in the upper or lower rectum were also evaluated separately.

RESULTS

Total agreement regarding rectocele and internal prolapse was 0.81 and 0.75, respectively (1.0 = complete agreement), and was significantly higher than chance agreement. Total agreement regarding residual volume in the rectum at the end of defecography and clinical relevance of findings was not different from chance agreement, providing clinical data did not significantly improve agreement. When residual volume was situated in the lower rectum, agreement regarding incompleteness of emptying and its clinical relevance was much better (0.93).

CONCLUSIONS

Interobserver agreement is good regarding the deformation of the rectum during defecography but not different from chance agreement regarding the completeness of evacuation.

Defecography. Results of investigations in 2,816 patients

PURPOSE

This study was designed to analyze the frequency of different findings at defecography in patients with defecation disorders and see in what way the evaluation could be improved.

METHODS

The reports of investigations in 2,816 patients were analyzed.

RESULTS

Twenty-three percent of the investigations were considered normal. Thirty-one percent of the patients had rectal intussusception, 13 percent had rectal prolapse, 27 percent had rectocele, and 19 percent had enterocele. Twenty-one percent of the patients had a combination of two or three of these diagnoses. The combination of rectocele and enterocele was rare. The majority of patients with enterocele had other concomitant findings. Patients with or without abnormal perineal descent had similar frequencies of rectal prolapse, rectal intussusception, and enterocele. Rectocele was more common in patients with abnormal perineal descent.

CONCLUSIONS

Defecography is valuable when investigating patients with defecation disorders. Pathologic findings were found in 77 percent of the patients. A standardized protocol should ensure a complete evaluation of defecography.

Reproducibility of five anorectal morphologic measurements in defecography

RATIONALE AND OBJECTIVES

We evaluated the inter- and intraobserver reproducibility of measuring five morphologic parameters of the anorectum in defecography (evacuation proctography).

METHODS

Measurements from 42 defecographic studies were statistically analyzed. The parameters measured during resting, squeezing, and straining included two anorectal angles (posterior and axis), maximal width of the anal canal, maximal width of the rectal lumen, and size of the rectocele.

RESULTS

The results demonstrated only fair interobserver agreement (kappa = 0.22-0.38) for almost all measurements of the five morphologic parameters. There were high correlations (kappa = 0.62-1.00) among most intraobserver measurements.

CONCLUSION

For defecographic measurement, the five parameters we studied have relatively poor clinical value because of high inter- and intraobserver inconsistency.

Patient position during cinedefecography. Influence on perineal descent and other measurements

PURPOSE

This study was undertaken to assess the reproducibility of cinedefecography measurements and abnormal findings between the left lateral decubitus and seated positions.

METHODS

Prospective patient evaluation included all patients who had lateral radiographs of the pelvis taken at rest, during squeezing, and pushing in both positions. Anorectal angle, perineal descent, and puborectalis length measurements were calculated for each set of radiographs. Pelvic floor dynamics during evacuation were measured as the changes between rest and pushing. Abnormal findings included both increased dynamic and fixed perineal descent, nonrelaxing puborectalis, and premature evacuation.

RESULTS

One hundred five consecutive patients underwent cinedefecography. There were statistically significant differences between the positions with regard to anorectal angle (P < 0.0001), perineal descent (P = 0.0001), and puborectalis length (P = 0.0001). Dynamic changes of the anorectal angle, perineal descent, and puborectalis length were not significantly different (P > 0.05). However, 6 of 22 (27 percent) patients with fecal incontinence had premature evacuation severe enough to impede measurement only when seated (P = 0.05).

CONCLUSION

Because of the statistically significant differences between the two positions, centers should always employ the same position for a given diagnostic group.

Does defecography help in diagnosis and clinical decision-making in defecation disorders?

Defecography is used to investigate patients with defecation disorders, especially obstructed defecation and anal incontinence. We studied 73 consecutive patients who complained of difficult defecation, anal incontinence, or idiopathic anorectal pain. The following defecographic parameters were recorded and compared in different patient groups: anorectal angulation, pelvic floor descent, formation of rectocele, and rectal invagination. Increasing number of childbirths correlated with pelvic floor descent in defecograms (r = 0.319, p < 0.05). There were no significant differences in defecographic parameters in patients with obstructed defecation, anal incontinence, or idiopathic anorectal pain. Thus, we conclude that defecography may be useful as an investigative tool in clinical research of defecation disorders, but it is of minor value in clinical diagnosis and decision-making.

Scintigraphic defecography: quantitative and dynamic assessment of anorectal function

PURPOSE

Conventional assessment of anorectal function with defecating videoproctography is semiquantitative and the high radiation exposure precludes prolonged or repeated testing. The aim of this study was to develop a dynamic scintigraphic method of assessing anorectal function.

METHODS

Fourteen patients with fecal incontinence, 18 patients with chronic constipation, and 8 control subjects were assessed by scintigraphic defecography. This involves introduction of a technetium-99m-radiolabeled artificial stool into the rectum of the subject and acquisition of gamma camera images during evacuation.

RESULTS

Mean evacuation rate was 2.8 percent/second in incontinent patients and 0.9 percent/second in constipated patients (P < 0.001). The mean anorectal angles were 136 degrees and 133 degrees, respectively. There were 18 cases of pelvic floor descent and 6 rectoceles. Scintigraphic defecography provides quantitative information on rectal evacuation. Anorectal angle and pelvic floor movement can be examined. The radiation dose to pelvic organs is significantly less than with videoproctography.

CONCLUSION

We believe that scintigraphic defecography is the investigation of choice for objective and dynamic assessment of anorectal function.

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.

The usefulness of tests in anorectal disease

Specialized tests of anorectal function are designed to complement but not to replace good clinical examination and sound professional judgement. The different methods of recording pressure changes have advantages and disadvantages. Poor correlation exists when data recorded using miniature balloons are compared with data from microtransducers. Prolonged ambulatory monitoring of anal sphincter and rectal pressure reveal that spontaneous transient episodes of sphincter relaxation are demonstrable in normal subjects. In the investigation of patients with possible traction injury to the pudendal nerve, electromyography and pudendal nerve terminal motor latency data are more precise than manometry data. Good correlation between noninvasive surface electromyography using an intra-anal plug electrode and anal manometry can be attained. Mapping of sphincter defects using concentric needle technology is reasonably accurate but distinctly painful. Dynamic defecography readily demonstrates abnormalities of the rectal wall. The division between what is normal and what is clinically relevant is rather imprecise. Comparative studies of sonographic and electromyographic mapping of sphincter defects give good correlation. Recent application of fine hooked electrodes have demonstrated periodic episodes of smooth muscle and sphincter relaxation. The saline infusion test and balloon expulsion test help to accurately quantify the difficulty patients experience in retention or evacuation, respectively. Perineometry is a simple, rapid, noninvasive method of measuring the extent of perineal descent on straining. Although reproducible, it tends to underestimate the degree of descent when compared with the radiological method but it avoids the use of ionized radiation.

Is the volume retained after defecation a valuable parameter at defecography?

The intention of this study was to correlate the retained volume at the end of defecography to certain defecographic findings and to the sense of incomplete emptying. In 170 defecographic series, the retained barium was estimated planimetrically. No particular defecographic finding determined a higher or lower amount of remaining volume, and the sense of incomplete evacuation did not depend on the amount of retained volume. Thresholds of urge and perception on anorectal manometry did not differ between patients with and without the feeling of incomplete evacuation. A rectocele, isolated or combined with an internal prolapse, caused the retained volume to be in the lowermost part of the rectum, whereas, in the case of an isolated intussusception, the remaining volume was located in the middle or higher part of the rectum. It is concluded that defecographic findings do not in general explain incomplete emptying or the sense of incomplete emptying, but they may determine the localization of the retained volume.

How reliable are currently available methods of measuring the anorectal angle?

A prospective study was undertaken to compare two different methods of measuring the anorectal angle (ARA), balloon proctography (BP) and cinedefecography (CD), as well as to evaluate the reproducibility of this measurement using each technique. One hundred four consecutive patients (75 women and 29 men) with constipation (63 patients), fecal incontinence (25 patients), or rectal pain (16 patients) underwent both BP and CD. The ARA was measured by taking lateral radiographs of the pelvis during rest (R), squeeze (S), and push (P). The same interpretation process was performed 2 to 12 months later by the same observer, blinded as to diagnosis and initial measurements. There were highly significant differences in each measurement category, R (P less than 0.0001), S (P less than 0.0001), and P (P less than 0.0004) between BP and CD. However, the correlation between the first and second measurements was excellent (P less than 0.0001). BP was consistently more difficult to interpret because of balloon configuration. Although BP and CD have poor correlation with each other, each examination can be reliably interpreted. CD appears to be a superior examination because of the added ability to delineate rectoceles, intussusceptions, and other structural defects.