Intraobserver and interobserver measurements of the anorectal angle and perineal descent 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.

The Role of Transperineal Ultrasound for the Assessment of the Anorectal Angle and Its Relationship with Levator Ani Muscle Avulsion

The relationship between the anorectal angle (ARA) and the levator ani muscle (LAM) is well known. In this study, we aimed to demonstrate that the ARA changes when LAM avulsion occurs after vaginal delivery. This was a secondary, observational retrospective study with data obtained from three previous studies. Using transperineal ultrasound, the presence of avulsion was assessed when abnormal insertion of the LAM was observed in three central slices. In addition, the ARA was assessed in the midsagittal plane (at rest, in Valsalva and at maximum contraction) as the angle between the posterior border of the distal part of the rectum and the central axis of the anal canal. The ARA was higher in patients with bilateral LAM avulsion than in patients without LAM avulsion at rest (131.8 ± 14.1 vs. 136.2 ± 13.8), in Valsalva (129.4 ± 15.5 vs. 136.5 ± 14.4) and at maximum contraction (125.7 ± 15.5 vs. 132.3 ± 13.2). The differences between both groups expressed as the odds ratio (OR) adjusted for maternal age were 1.031 (95% confidence interval (CI), 1.001–1.061; p = 0.041) at rest, 1.036 (95% CI, 1.008–1.064; p = 0.012) in Valsalva and 1.031 (95% CI, 1.003–1.059; p = 0.027) at maximum contraction. In conclusion, LAM avulsion produces an increase in the ARA at rest, during contraction and in Valsalva, especially in cases of bilateral LAM avulsion.

Dynamic fluoroscopic defecography: updates on rationale, technique, and interpretation from the Society of Abdominal Radiology Pelvic Floor Disease Focus Panel

Whether used as the primary diagnostic test or reserved as a problem-solving examination, fluoroscopic defecography (FD) remains an important tool in the workup and treatment of defecatory disorders. FD is a well-established, simple, and rapid examination that most closely resembles the actual process and position that a patient uses to enable defecation and provides both qualitative and quantitative information on the defecatory process. FD is indicated when re-creating the act of defecation is necessary, especially in patients with symptoms of obstructed defecation and where symptoms do not correlate with prior examinations such as MRI. Also, FD may help the patient understand the severity of their condition, better informing them of the structural and functional pathology, and aid in discussions with the surgeon regarding plans for treating their complex pelvic floor and defecatory problems. This review provides an up-to-date, comprehensive summary of FD and describes the indications for, techniques of, and common pathology encountered.

Anorectal angle at rest predicting successful sacral nerve stimulation in idiopathic fecal incontinence-a cohort analysis

PURPOSE

Sacral nerve stimulation is an effective treatment for patients suffering from fecal incontinence. However, less is known about predictors of success before stimulation. The purpose of this study was to identify predictors of successful sacral nerve stimulation in patients with idiopathic fecal incontinence.

METHODS

Consecutive female patients, receiving peripheral nerve evaluation and sacral nerve stimulation between September 2008 and October 2014, suffering from idiopathic fecal incontinence were included in this study. Preoperative patient's characteristics, anal manometry, and defecography results were collected prospectively and investigated by retrospective analysis. Main outcome measures were independent predictors of treatment success after sacral nerve stimulation.

RESULTS

From, all in all, 54 patients suffering from idiopathic fecal incontinence receiving peripheral nerve evaluation, favorable outcome was achieved in 23 of 30 patients after sacral nerve stimulation (per protocol 76.7%; intention to treat 42.6%). From all analyzed characteristics, wide anorectal angle at rest in preoperative defecography was the only independent predictor of favorable outcome in multivariate analysis (favorable 134.1 ± 13.9° versus unfavorable 118.6 ± 17.1°).

CONCLUSIONS

Anorectal angle at rest in preoperative defecography might present a predictor of outcome after sacral nerve stimulation in patients with idiopathic fecal incontinence.

The anatomy of transanal minimally invasive surgery: Perineal distances and transanal angles

The recent interest in transanal, minimally invasive surgery has highlighted the importance of an in depth understanding of this complex region. We applied data from an anatomical study of the perineum to the concept of transanal minimally invasive surgery with the aim to describe more accurately anatomy relevant to this surgical technique. A consecutive series of adult patients undergoing colonoscopy were approached for consent to measure dimensions and angles of the perineum before the examination. Distances from the posterior margin of the anus to the coccyx, and the anterior margin of the anus to the posterior edge of the scrotum or introitus were measured. Then, using a pediatric proctoscope and a protractor, the anoperineal angle and the recto perineal angles were measured. The anorectal angle was derived from these measurements. Data is described using means and standard deviations. Measurements were obtained from 106 patients undergoing elective colonoscopy for average risk screening with no history of defecatory disorder. Posterior perineal length was similar in both sexes (4.5 cm ± 0.9 in women and 4.6 cm ±0.7 in men) but the anterior perineum was significantly shorter in women (2.5 ± 0.8). The mean anoperineal angle was 93° (±9), and mean rectoperineal angle was 73° (±9). These angles varied significantly between the sexes. The mean anorectal angle (derived) was 160° (±9), and did not differ significantly between the sexes. There was no correlation between the posterior perineal length and ano perineal, recto perineal, or anorectal angles. Limitations: small sample size. Anoperineal and recto perineal differ significantly between the sexes. Surgeons using transanal minimally invasive surgical techniques should expect to alter the alignment of their dissection accordingly. This study shows the magnitude of the differences that can exist. Clin. Anat. 32:68-72, 2019. © 2018 Wiley Periodicals, Inc.

Correlation Between Echodefecography and 3-Dimensional Vaginal Ultrasonography in the Detection of Perineal Descent in Women With Constipation Symptoms

BACKGROUND

Defecography is an established method of evaluating dynamic anorectal dysfunction, but conventional defecography does not allow for visualization of anatomic structures.

OBJECTIVE

The purpose of this study was to describe the use of dynamic 3-dimensional endovaginal ultrasonography for evaluating perineal descent in comparison with echodefecography (3-dimensional anorectal ultrasonography) and to study the relationship between perineal descent and symptoms and anatomic/functional abnormalities of the pelvic floor.

DESIGN

This was a prospective study.

SETTING

The study was conducted at a large university tertiary care hospital.

PATIENTS

Consecutive female patients were eligible if they had pelvic floor dysfunction, obstructed defecation symptoms, and a score >6 on the Cleveland Clinic Florida Constipation Scale.

INTERVENTIONS

Each patient underwent both echodefecography and dynamic 3-dimensional endovaginal ultrasonography to evaluate posterior pelvic floor dysfunction.

MAIN OUTCOME MEASURES

Normal perineal descent was defined on echodefecography as puborectalis muscle displacement ≤2.5 cm; excessive perineal descent was defined as displacement >2.5 cm.

RESULTS

Of 61 women, 29 (48%) had normal perineal descent; 32 (52%) had excessive perineal descent. Endovaginal ultrasonography identified 27 of the 29 patients in the normal group as having anorectal junction displacement ≤1 cm (mean = 0.6 cm; range, 0.1-1.0 cm) and a mean anorectal junction position of 0.6 cm (range, 0-2.3 cm) above the symphysis pubis during the Valsalva maneuver and correctly identified 30 of the 32 patients in the excessive perineal descent group. The κ statistic showed almost perfect agreement (κ = 0.86) between the 2 methods for categorization into the normal and excessive perineal descent groups. Perineal descent was not related to fecal or urinary incontinence or anatomic and functional factors (sphincter defects, pubovisceral muscle defects, levator hiatus area, grade II or III rectocele, intussusception, or anismus).

LIMITATIONS

The study did not include a control group without symptoms.

CONCLUSIONS

Three-dimensional endovaginal ultrasonography is a reliable technique for assessment of perineal descent. Using this technique, excessive perineal descent can be defined as displacement of the anorectal junction >1 cm and/or its position below the symphysis pubis on Valsalva maneuver.

Energy intake over 2 days is unaffected by acute sprint interval exercise despite increased appetite and energy expenditure

A cumulative effect of reduced energy intake, increased oxygen consumption, and/or increased lipid oxidation could explain the fat loss associated with sprint interval exercise training (SIT). This study assessed the effects of acute sprint interval exercise (SIE) on energy intake, subjective appetite, appetite-related peptides, oxygen consumption, and respiratory exchange ratio over 2 days. Eight men (25 ± 3 years, 79.6 ± 9.7 kg, body fat 13% ± 6%; mean ± SD) completed 2 experimental treatments: SIE and recovery (SIEx) and nonexercise control. Each 34-h treatment consisted of 2 consecutive 10-h test days. Between 0800-1800 h, participants remained in the laboratory for 8 breath-by-breath gas collections, 3 buffet-type meals, 14 appetite ratings, and 4 blood samples for appetite-related peptides. Treatment comparisons were made using 2-way repeated measures ANOVA or t tests. An immediate, albeit short-lived (<1 h), postexercise suppression of appetite and increase in peptide YY (PYY) were observed (P < 0.001). However, overall hunger and motivation to eat were greater during SIEx (P < 0.02) without affecting energy intake. Total 34-h oxygen consumption was greater during SIEx (P = 0.04), elicited by the 1491-kJ (22%) greater energy expenditure over the first 24 h (P = 0.01). Despite its effects on oxygen consumption, appetite, and PYY, acute SIE did not affect energy intake. Consequently, if these dietary responses to SIE are sustained with regular SIT, augmentations in oxygen consumption and/or a substrate shift toward increased fat use postexercise are most likely responsible for the observed body fat loss with this type of exercise training.

Descending perineum syndrome: a review of the presentation, diagnosis, and management

INTRODUCTION AND HYPOTHESIS

Defecatory dysfunction is a relatively common and challenging problem among women and one that practicing pelvic reconstructive surgeons and gynecologists deal with frequently. A subset of defecatory dysfunction includes obstructed defecation, which can have multiple causes, one of which is descending perineum syndrome (DPS).

METHODS

A literature search was performed to identify the pathophysiology, diagnosis, and management of DPS.

RESULTS

Although DPS has been described in the literature for many decades, it is still uncommonly diagnosed and difficult to manage. A high index of suspicion combined with physical examination consistent with excess perineal descent, patient symptom assessment, and imaging in the form of defecography are required for the diagnosis to be accurately made. Primary management options of DPS include conservative measures consisting of bowel regimens and biofeedback. Although various surgical approaches have been described in limited case series, no compelling evidence can be demonstrated at this point to support surgical intervention.

CONCLUSIONS

Knowledge of DPS is essential for the practicing pelvic reconstructive surgeon to make a timely diagnosis, avoid harmful treatments, and initiate therapy early on.

Evacuation proctography: a reappraisal of normal variability

AIM

Interpretation of evacuation proctography (EP) images is reliant on robust normative data. Previous studies of EP in asymptomatic subjects have been methodologically limited. The aim of this study was to provide parameters of normality for both genders using EP.

METHOD

Evacuation proctography was prospectively performed on 46 healthy volunteers (28 women). Proctograms were independently analysed by two reviewers. All established and some new variables of defaecatory structure and function were assessed objectively: anorectal dimensions; anorectal angle changes; evacuation time; percentage contrast evacuated; and incidence of rectal wall morphological 'abnormalities'.

RESULTS

Normal ranges were calculated for all main variables. Mean end-evacuation time was 88 s (95% CI: 63-113) in male subjects and 128 s (95% CI: 98-158) in female subjects; percentage contrast evacuated was 71% (95% CI: 63-80) in male subjects and 65% (95% CI: 58-72) in female subjects. Twenty-six (93%) of 28 female subjects had a rectocoele with a mean depth of 2.5 cm (upper limit = 3.9 cm). Recto-rectal intussusception was found in nine subjects (approximately 20% of both genders); however, recto-anal intussusception was not observed. Only rectal diameter differed significantly between genders. Qualitatively, three patterns of evacuation were present.

CONCLUSION

This study defines normal ranges for anorectal dimensions and parameters of emptying, as well as the incidence and characteristics of rectal-wall 'abnormalities' observed or derived from EP. These ranges can be applied clinically for subsequent disease comparison.

Three-dimensional high-resolution anorectal manometry and diagnosis of excessive perineal descent: a comparative pilot study with defaecography

AIM

Three-dimensional high-resolution anorectal manometry (3DHRAM) is a new technique that can simultaneously provide physiological and topographical data on the terminal part of the digestive tract. Our object was to assess whether 3DHRAM is able to reliably diagnose excessive perineal descent already diagnosed with conventional defaecography, which is considered to be the gold standard.

METHOD

All patients referred to our centre for anorectal manometry and conventional defaecography were evaluated with a maximum of 6 months between the two examinations. Anorectal manometry was performed using the 3D High-Resolution Given Imaging® probe. Excessive perineal descent was defined as the downward movement of the anal high-pressure zone during straining. At the end of the straining effort, the high-pressure zone regained its initial position, thereby indicating that the probe had not moved.

RESULTS

Nineteen female patients of median age 53 (21-70) years were included in the study. All cases with excessive perineal descent diagnosed using defaecography were visualized with 3DHRAM. The degree of perineal descent determined by 3D and conventional defaecography was compared (Spearman correlation 0.726, P = 0.01). In contrast, the averages measured were significantly different; the average was 11.68 ± 3.3 mm for 3DHRAM but 34.21 ± 13.3 mm for conventional defaecography (P = 0.002).

CONCLUSION

The results of the study demonstrate that 3DHRAM can diagnose excessive perineal descent with the same degree of reliability as defaecography. Quantitative measures were not correlated, however, possibly because of methodological differences. The study confirms the value of the morphological data provided by 3DHRAM.

Evaluation of constipation

The evaluation of the chronically constipated patient is multifaceted and challenging. Many clinicians define constipation according to the latest Rome III diagnostic criteria for functional gastrointestinal disorders. Female sex, older age, low fiber diet, a sedentary life style, malnutrition, polypharmacy, and a lower socioeconomic status have all been identified as risk factors for functional constipation. In elderly patients, it is important to rule out a colonic malignancy as the cause of constipation. The initial evaluation of the constipated patient includes a detailed history to elicit symptoms distinguishing slow transit constipation from obstructive defecation. Slow transit and obstructive defecation are the two major subtypes of functional constipation. In addition, the clinician should identify any secondary causes of constipation. The office examination of the constipated patient includes an abdominal, perineal, and a rectal exam. Many patients improve with lifestyle modification. When dietary interventions and lifestyle modifications fail, many diagnostic studies are available to further evaluate the constipated patient. Sitzmark transit study, nuclear scintigraphic defecography, electromyography, anorectal manometry, balloon expulsion test, paradoxical puborectalis contraction, cinedefecography, and dynamic magnetic resonance imaging defecography have all been used to diagnose the underlying causes of functional constipation.

Perineal descent does not imply a more severe clinical disorder

AIM

There is poor consensus in the literature about measuring perineal descent. We aimed to assess symptoms and quality of life in constipated patients with abnormal perineal descent.

METHOD

Constipated patients were categorized into those with obstructed defaecation, colonic inertia, mixed disorders and irritable bowel syndrome constipation types. Anal physiology was performed. KESS score, Irritable Bowel Syndrome Quality of Life and SF-12 questionnaires were completed. The position of the perineum was measured by defaecography. Patients were divided into two groups according to the position of the perineal descent at rest: group 1 (normal < 3.5 cm) and group 2 (abnormal > 3.5 cm).

RESULTS

Fifty-eight patients were identified, 23 (40%) in group 1 and 35 (60%) in group 2. Patients in group 2 were older (P = 0.007), had a higher body mass index (BMI; P = 0.003), a higher rate of hysterectomy (P = 0.04) and more vaginal deliveries (P = 0.001). Obstructed defaecation was the predominant subtype of constipation. Group 1 had more difficulty in initiating defaecation and group 2 presented more cases with intussusception and enterocele (P = 0.03 for both). Group 2 had a lesser degree of perineal descent between rest and straining. Rectal compliance was greater in group 2 (P = 0.03). Symptoms and quality of life scores were similar between the groups.

CONCLUSION

Radiologically determined excessive perineal descent is not indicative of worse symptoms or quality of life. This radiological finding does not warrant further investigation.

How to interpret a functional or motility test - defecography

Defecography evaluates in real time the morphology of rectum and anal canal in a physiologic setting by injection of a thick barium paste into the rectum and its subsequent evacuation. Because of its ability of structural and functional evaluation, defecography is primarily performed for work up of patients with longstanding constipation, unexplained anal or rectal pain, residual sensation after defecation or suspected prolapse. Technique and interpretation of this examination are outlined in this review.

Pelvic floor imaging

Pelvic floor ultrasound is a valuable adjunct in elucidation of cause, diagnosis, and treatment of pelvic floor disorders. Three-dimensional ultrasound specifically has been shown to have many advantages over conventional imaging modalities. Proper evaluation of pelvic floor muscle function, strength, and integrity is an important component of diagnosis and treatment of pelvic floor disorders. The pelvic floor muscle training used to change the structural support and strength of muscle contraction requires clinicians to be able to conduct high-quality measurements of pelvic floor muscle function and strength. Ultrasound is a useful modality to assess the pelvic floor and its function. As practitioners become more familiar with the advantages and capabilities of ultrasound, this tool should become part of routine clinical practice in evaluation and management of pelvic floor disorders.

Effects and reproducibility of aerobic and resistance exercise on appetite and energy intake in young, physically active adults

Appetite and meal energy intake (MEI) following aerobic (AEx) and resistance (REx) exercises were evaluated in 19 young, active adults. The participants completed duplicate 35-min sessions of AEx, REx, and sedentary control, and consumed an ad libitum pasta meal 30 min postsession. Hunger transiently decreased after AEx but was not influenced by REx. MEI was 14% to 18% higher after AEx and REx than control. These findings are consistent with exercise-stimulated ingestive behavior, not anorexia of exercise.

Paradoxical puborectalis contraction and increased perineal descent

Paradoxical puborectalis contraction and increased perineal descent are two forms of functional constipation presenting as challenging diagnostic and treatment dilemmas to the clinician. In the evaluation of these disorders, the clinician should take special care to exclude anatomic disorders leading to constipation. Physical examination is supplemented by additional diagnostic modalities such as cinedefecography, electromyography, manometry, and pudendal nerve tefninal motor latency. Generally, these investigations should be used in combination with the two playing the more relied upon techniques. Treatment is typically conservative with biofeedback playing a principal role with favorable results when patient compliance is emphasized. When considering paradoxical puborectalis contraction, failure of biofeedback is usually augmented with botulinum toxin injection. Increased perineal descent is generally treated with biofeedback and perineal support maneuvers. Surgery has little or no role in these conditions. The patient who insists on surgical intervention for either of these two conditions should be offered a stoma.

Functional anorectal disorders

Functional anorectal disorders include solitary rectal ulcer syndrome, rectocele, nonrelaxing puborectalis syndrome, and descending perineal syndrome. Patients usually present with "constipation," but the clinical picture of these disorders includes rectal pain and bleeding, digitalization, incomplete evacuation, and a feeling of obstruction. Diagnosis is difficult because many findings can be seen in normal patients as well. The diagnosis is made by using a combination of clinical picture, defecography, pathology, and occasionally anometry and pudendal terminal motor nerve latency. These disorders are generally treated medically with dietary changes and biofeedback. Surgical intervention is reserved for patients with intractable symptoms and has not been universally successful.

Gender influence on defecographic abnormalities in patients with posterior pelvic floor disorders

AIM

To compare defecographic abnormalities in symptomatic men and women and to analyze differences between men and age- and symptom-matched women.

METHODS

Sixty-six men (mean age: 55.4 years, range: 20-81 years) who complained of constipation and/or fecal incontinence and/or pelvic pain underwent defecography after intake of a barium meal. Radiographs were analyzed for the diagnosis of rectocele, enterocele, intussusception and perineal descent. They were compared with age- and symptom-matched women (n = 198) who underwent defecography during the same period.

RESULTS

Normal defecography was observed in 22.7% of men vs 5.5% of women (P < 0.001). Defecography in men compared with women showed 4.5% vs 44.4% (P < 0.001) rectocele, and 10.6% vs 29.8% (P < 0.001) enterocele, respectively. No difference was observed for the diagnosis of intussusception (57.6% vs 44.9%). Perineal descent at rest was more frequent in women (P < 0.005).

CONCLUSION

For the same complaint, diagnosis of defecographic abnormalities was different in men than in women: rectocele, enterocele and perineal descent at rest were observed less frequently in men than in women.

Influence of Body Position on Defecation in Humans

OBJECTIVES

To compare three positions for defecation by measuring abdominal pressure and the anorectal angle simultaneously.

METHODS

We recruited six healthy volunteers. The videomanometric measures included simultaneous fluoroscopic images, abdominal pressures, subtracted rectal pressures and anal sphincter pressures. Three positions were used: sitting, sitting with the hip flexing at 60 ° with respect to the rest of the body, and squatting with the hip flexing at 22.5 ° with respect to the rest of the body.

RESULTS

Basal abdominal pressure before defecation on hip-flex sitting was lower than that with normal sitting, although the difference did not reach statistical significance. Basal abdominal pressure before defecation on squatting (26 cmH2 O) was lower than that with normal sitting (P < 0.01). Abdominal pressure increase (strain) on hip-flex sitting was lower than that with normal sitting, although this difference did not reach statistical significance. Similarly, the abdominal pressure increase on squatting was smaller than that with normal sitting, and yet the difference did not reach statistical significance. The rectoanal angle on defecation on hip-flex sitting did not differ from that with normal sitting. The rectoanal angle on defecation on squatting (126 °) was larger than that with normal sitting (100 °) (P < 0.05), and was also larger than that with hip-flex sitting (99 °) (P < 0.01).

CONCLUSION

The results of the present study suggest that the greater the hip flexion achieved by squatting, the straighter the rectoanal canal will be, and accordingly, less strain will be required for defecation.

Reproducibility of energy intake, gastric emptying, blood glucose, plasma insulin and cholecystokinin responses in healthy young males

Gastric emptying, as well as intragastric meal distribution, and gastrointestinal hormones, including cholecystokinin (CCK), play an important role in appetite regulation. The evaluation of gastrointestinal factors regulating food intake is commonly performed in healthy, lean, young male participants. It has, however, been suggested that there is a marked interindividual variability in the effects of nutrient 'preloads' on energy intake in this group. Whether there is significant intraindividual variation in acute energy intake after a nutrient preload, and, if so, how this relates to day-to-day differences in gastric emptying and gastrointestinal hormone release, is unclear. The purpose of the present paper is to evaluate the hypothesis that energy intake after a nutrient preload would be reproducible and associated with reproducible patterns of gastric emptying, intragastric distribution and gastrointestinal hormone release. Fifteen healthy men (age 25 (sem 5) years) consumed a glucose preload (50 g glucose in 300 ml water; 815 kJ) on three occasions. Gastric emptying and intragastric meal distribution (using three-dimensional ultrasound), blood glucose, plasma insulin and CCK concentrations and appetite perceptions were evaluated over 90 min, and energy intake from a cold buffet-style meal was then quantified. Energy intake was highly reproducible within individuals between visits (intraclass correlation coefficient, ri = 0.9). Gastric emptying, intragastric meal distribution, blood glucose, plasma insulin and CCK concentrations and appetite perceptions did not differ between visits (ri>0.7 for all). In healthy males, energy intake is highly reproducible, at least in the short term, and is associated with reproducible patterns of gastric emptying, glycaemia, insulinaemia and CCK release.

Perineal descent predicted by a pelvic bone factor: the pelvic incidence angle

PURPOSE

By measuring the pelvic incidence angle, we assessed the relationship between pelvic floor disorders and pelvic morphology, which allowed us to document for the first time the hypothesis that pelvic incidence may be a predictive factor of perineal descent.

METHODS

In a retrospective study of 197 women, the perineal descent at rest and during straining was assessed by defecography. The pelvic incidence angle (53 degrees +/- 9 degrees , independent of the subject position) was defined as the angle between the line perpendicular to the sacral plate at its midpoint and the line connecting this point to the middle of the femoral heads axis. The pelvic incidence angle was correlated with the incidence of pelvic floor descent.

RESULTS

In those with pelvic floor descent at rest compared with those without, pelvic incidence angle was significantly larger (64 degrees vs. 53 degrees , P < 10E-06). As a predictive factor of perineal descent at rest, a great pelvic incidence (>62 degrees ) had a sensitivity (73 percent), specificity (82 percent), positive predictive value (81 percent), and negative predictive value (75 percent).

CONCLUSIONS

A large pelvic incidence (>62 degrees ) may be a predictive factor of perineal descent at rest before the apparition of other acquired factors. With pelvic incidence >62 degrees , a large overhang between the insertions increases the strains on the perineum, which is rather horizontal.

Radiologic evaluation of pelvic floor disorders

Several imaging modalities are available ranging from fluoroscopic techniques to ultrasonography and MRI for the evaluation of patients with pelvic floors disorders. High-resolution ultrasonography and MRI not only provide superior delineation of the pelvic floor anatomy but also reveal pathology and functional changes. This article focuses on standard imaging procedures including defecography, ultrasonography, and MRI and discusses its use in clinical practice by illustrating both normal and abnormal patterns.

Closure mechanism of the anal canal in women: assessed by three-dimensional ultrasound imaging

PURPOSE

To describe the functional correlates of anal canal anatomy using 3 dimensional ultrasound imaging.

METHODS

Ten nulliparous women were studied by using a 10-cm bag of 20-mm diameter. The bag was placed along the anal canal and inflated with 20 to 45 ml water, in 5-ml increments. At each volume, a three-dimensional ultrasound volume of the anal canal was obtained while the subjects were at rest and squeeze. The ultrasound images were analyzed to determine the relationship between the bag cross-sectional area and bag pressure.

RESULTS

At low distension volumes, the bag is shaped like an "hourglass." The flared ends of the funnels correspond with the proximal and distal margins of the puborectalis muscle and external anal sphincter respectively. With increasing bag volumes, the length of completely closed segment of anal canal decreased. The last anal segment to open at rest was the one surrounded by all three structures. Anal contraction resulted in reduction of the anal canal cross-sectional area; the least compliant part of the anal canal was the one surrounded by external anal sphincter.

CONCLUSION

The internal anal sphincter, external anal sphincter, and puborectalis muscle are all involved in the anal canal closure function. During contraction, the external anal sphincter is the strongest component of anal canal closure mechanism.

Effects of pelvic floor muscle contraction on anal canal pressure

The role of pelvic floor muscle contraction in the genesis of anal canal pressure is not clear. Recent studies have suggested that vaginal distension increases pelvic floor muscle contraction. We studied the effects of vaginal distension on anal canal pressure in 15 nullipara asymptomatic women. Anal pressure, rest, and squeeze were measured using station pull-through manometry techniques with no vaginal probe, a 10-mm vaginal probe, and a 25-mm vaginal probe in place. Rest and squeeze vaginal pressures were significantly higher when measured with the 25-mm probe compared with the 10-mm probe, suggesting that vaginal distension enhances pelvic floor contraction. In the presence of the 25-mm vaginal probe, rest and squeeze anal pressures in the proximal part of the anal canal were significantly higher compared with no vaginal probe or the 10-mm vaginal probe. On the other hand, distal anal pressures were not affected by any of the vaginal probes. Ultrasound imaging of the pelvic floor revealed that vaginal distension increased the anterior-posterior length of the puborectalis muscle. Atropine at 15 micro g/kg had no influence on the rest and squeeze anal pressures with or without vaginal distension. Our data suggest that pelvic floor contractions increase pressures in the proximal part of the anal canal, which is anatomically surrounded by the puborectalis muscle. We propose that pelvic floor contraction plays an important role in the fecal continence mechanism by increasing anal canal pressure.

Dynamic imaging of posterior compartment pelvic floor dysfunction by evacuation proctography: techniques, indications, results and limitations

The clinical management of patients with anorectal and pelvic floor dysfunction is often difficult. Evacuation proctography has evolved from a method to evaluate the anorectum for functional disorders to its current status as a practical method for evaluating anorectal dysfunction and pelvic floor prolapse. It has a high observer accuracy and yield of positive diagnosis. Clinicians find it of major benefit and has altered management from surgical to medical and vice versa in a significant number of cases.

Functional correlates of anal canal anatomy: puborectalis muscle and anal canal pressure

BACKGROUND

Resting and squeeze pressures in the anal canal are thought to reflect the contributions of the internal anal sphincter (IAS) and the external anal sphincter (EAS) respectively. Role of the puborectalis muscle (PRM) in the genesis of anal canal pressure is not known.

OBJECTIVES

To determine the functional correlates of anal canal anatomy.

METHODS

Seventeen asymptomatic nulliparous women were studied using simultaneous 3D ultrasound images and manometry of the anal canal. Ultrasound images were recorded using a transducer placed at the vaginal introitus and pressures were recorded with a side-hole manometry catheter using a station (every 5 mm) pull-through technique. Pressures were recorded at rest and during voluntary squeeze.

RESULTS

Anal canal high pressure zone was 39 +/- 1 mm in length. The IAS, EAS, and PRM were clearly visualized in the ultrasound images. EAS was located in the distal (length 19 +/- 1 mm) and PRM in the proximal part (length 18 +/- 1 mm) of the anal canal. The station pull-through technique revealed increases in pressure with voluntary squeeze in the proximal as well as distal parts of the anal canal. Proximal anal canal pressure, located in the PRM zone, showed greater circumferential asymmetry than the distal anal canal pressure, located in the EAS zone.

CONCLUSIONS

(1) PRM contributes to the squeeze pressure in the proximal part of the anal canal and EAS to the distal anal canal. (2) PRM squeeze-related increase in anal canal pressure might be important in the anal continence mechanism.

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.

Abdominal rectopexy for complete rectal prolapse: preliminary results of a new technique

PURPOSE

Although the technique for the surgical repair of rectal prolapse has advanced over the years, no ideal procedure has been found. We aim to test a new surgical procedure for abdominal rectopexy that uses the greater omentum to support the rectum below the rectopexy, to reconstruct the anorectal angle and dispense with the need for synthetic mesh, thus reducing the risk of infection.

METHODS

A series of ten patients, all young and medically fit, underwent repair surgery for rectal prolapse with the new rectopexy technique. Some patients had concomitant sigmoidectomy. Preoperative and postoperative assessment included a clinical examination, anal manometry and defecography.

RESULTS

Follow-up lasted a mean of 56.4 months. None of the patients had recurrent rectal prolapse or infection. Postoperative assessment at 24 months disclosed significant improvements in all the bowel and sphincter variables assessed. The 8 patients who had severe incontinence preoperatively had notably improved and 4 were fully continent, 3 moderately incontinent, and only 1 patient had persistently high levels of incontinence. In only 1 patient who initially had severe incontinence, continence completely regressed and severe constipation developed. Maximal basal pressure values increased significantly after surgery (p=0.0025), although they increased slightly less evidently in patients in whom marked incontinence persisted at postoperative follow-up. Maximal voluntary contraction pressure also increased significantly after surgery (p=0.0054), although the values changed less than those for basal pressure. During rest, squeeze and straining, and in all the patients who regained continence, even those who recovered it only partly, surgery substantially reduced the anorectal angle. The reduction during rest was statistically significant (p=0.0062).

CONCLUSIONS

The rectopexy technique we tested in patients with rectal prolapse avoids the need for synthetic mesh, and provides good results in terms of bowel and sphincter function, without infection or recurrence.

Dynamic evaluation of the anorectum

The evaluation of EP is complicated by the lack of any gold standard and a shifting clinical emphasis as management regimens go in and out of favor. As with all functional bowel disease, there is a residue of patients who are difficult to manage, and in whom a clinician will want maximum information before deciding on treatment. The examination has been criticized as lacking clinical relevance, and of having poor interobserver reliability except for rectal emptying and rectocele formation. Others have found a higher (83.3%) observer accuracy and a high yield of positive diagnoses. A questionnaire showed that clinicians found EP of major benefit in 40%, altering management from surgical to medical in 14% and vice versa in 4%. Radiographic examinations only impact on clinical management when findings alter management. Management protocols are evolving in functional disorders, but important features that EP reveals are anismus, trapping in rectoceles, IAI, and rectal prolapse. EP is the only method to diagnose some of these conditions and within defined parameters is extremely valuable in clinical management.