Anorectal anatomy and imaging techniques

Anal and Perianal Masses: The Common, the Uncommon, and the Rare

A variety of tumors involve the anal canal because the anal canal forms the transition between the digestive system and the skin, and this anatomical region is made of a variety of different cells and tissues. Magnetic resonance imaging (MRI) is the modality of choice for diagnosis and local staging of the anal canal and perianal neoplasms. In this pictorial review, we demonstrate the MRI anatomy of the anal canal and perianal region and display the imaging spectrum of tumors in the region along with an overview of its management. Imaging appearances of many tumorlike lesions that can cause diagnostic dilemmas are also demonstrated with pointers to differentiate between them.

Pelvic Floor Disorders Due to Anal Sexual Activity in Men and Women: A Narrative Review

Recent evidence shows that consensual anal penetrative intercourse has become more prevalent, not only limited to gay, bisexual, and other men who have sex with men but also for women who are in a sexual relationship with men. The aim of this review was to study the influence of consensual anal intercourse on pelvic floor function and the role of pelvic floor physical therapy treatment in preventing or treating consensual anal intercourse-induced anodyspareunia and/or fecal incontinence. We reviewed 68 references that showed that anal penetrative intercourse is a risk factor for anodyspareunia and fecal incontinence in both men and women. This risk of anal intercourse may increase with emotional discomfort, an overactive pelvic floor, lack of lubrication, frequency of anal penetrative intercourse, and hard practice (BDSM: bondage and discipline, dominance and submission, sadism, and masochism). It seems that pelvic floor physical therapists play an essential role in preventing and treating pelvic floor dysfunctions due to anal intercourse, which can lead to anodyspareunia and fecal incontinence; the treatment includes education, pelvic floor training with and without biofeedback, electric stimulation, manual therapy, and dilatators. Further studies are warranted to enhance our understanding of the causes and treatment efficacy of pelvic floor dysfunctions due to anal penetrative intercourse.

Multimodality imaging of pelvic floor anatomy

The pelvic floor is composed of a network of muscles, ligaments, and fasciae, which provide active and passive support for the pelvic organs. Impairment of these pelvic floor elements can result in a variety of functional abnormalities and single or multicompartment organ prolapse. Knowledge of normal pelvic floor anatomy can aid the radiologist in understanding the complex nature of pelvic floor dysfunction and is important for comprehensive image interpretation. This article provides an overview of normal anatomy of the pelvic floor as seen on magnetic resonance imaging, ultrasound, and fluoroscopic studies performed in the evaluation of pelvic floor function.

The use of dynamic MR imaging in patients with clinical pelvic floor disorders

OBJECTIVES

To determine the differences and challenging aspects of dynamic magnetic resonance defecography (MRD) compared to conventional defecography (CD) in diagnostic of clinical symptomatic pelvic floor dysfunction.

METHODS

Fifty patients (44 females, 6 males; mean age: 57 years) with symptomatic pelvic floor dysfunction underwent both examinations, CD and MRD. Results were retrospectively intra-individual and interindividual evaluated in this multicentre study. Visibility and accuracy in diagnosis and classification of rectal prolapse, rectocele, enterocele, sigma diverticula and Cul-de-sac phenomenon/syndrome were observed. Differences were analysed using Mann-Whitney U test. P-values < 0.05 were considered as statistically significant.

RESULTS

CD was significantly superior to MRD in diagnosis and grading of rectal prolapse (p < .001), diagnosis and metric measurements of rectoceles (p = .016), diagnosis of elongated sigmoid colon (p = .008) and Cul-de-sac phenomenon and syndrome, respectively (p = .015; p = .008). MRD revealed equal results to CD in detection, localization, tendency to retention and enlargement of rectoceles (p = .337) and findings of enteroceles (p = .604) as well as sigma diverticula (p = .149).

CONCLUSIONS

The complementary use of both examination methods, CD and MRD, is important to achieve a comprehensive look on every aspect of pelvic floor disorders and gain optimal results in detection and evaluation of all major disorders of the pelvic floor.

A comprehensive physical therapy evaluation for Male Chronic Pelvic Pain Syndrome: A case series exploring common findings

INTRODUCTION

Male Chronic Pelvic Pain Syndrome (MCPPS) is a complex condition and difficult to decipher due to the multifactorial etiologies and system interrelationships. No studies to date have described a movement-based, multisystem assessment including the musculoskeletal, visceral, nervous, lymphatic and vascular systems, as well as manual prostate mobility testing. The purpose of this paper is to demonstrate the importance of a comprehensive physical therapy evaluation to identify predominant mechanical and movement-based dysfunctions related to multiple anatomical structures and their interrelationships. Furthermore, symptoms and potentially confounding psychosocial, and environmental factors linked to MCPPS will be presented, and an overview of prospective treatment will be provided.

METHOD

A retrospective analysis of evaluative findings for ten men was performed. The men, with an average age 35 (range 24-46) were referred to physical therapy for MCPPS.

RESULTS

This retrospective analysis of ten patients identifies potential contributing pain factors associated with MCPPS. Similarities in clinical presentation among men suffering from MCPPS were identified to include predominant mechanical dysfunctions of the thoraco-lumbar spine, the liver, the kidney, the femoral nerve, the bladder, the prostate, and the pelvic floor.

CONCLUSION

The observations in this retrospective study demonstrate that the use of a multisystem assessment approach in patients with MCPPS is critical for their more effective treatment. On the basis of these findings, and the close mechanical interrelationships of the anatomical elements involved and multisystem MCPPS etiologies, larger-scale research is warranted.

MRI anatomy and pathology of the anal canal

The normal function of the anal sphincter complex is crucial for quality of life, as it is the mechanism by which fecal continence is maintained. Additionally, the anal sphincter complex is an integral part of the coordinated effort of defecation. As imaging plays an important role in assessment of pathologic conditions involving the anal region, understanding the normal anatomy of the anal sphincter complex is important for correct image interpretation and accurate diagnosis. This review discusses the anatomy and function of the anal sphincter complex, important technical considerations for MRI, and various inflammatory, infectious, and neoplastic processes, as well as pathologic structural conditions that affect the anal region. Level of Evidence: 5 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2019;50:1018-1032.

Defecography: An Overview of Technique, Interpretation, and Impact on Patient Care

Pelvic floor and defecatory dysfunction are common in the female patient population. When combined with physical examination, barium defecography allows for accurate and expanded assessment of the underlying pathology and helps to guide future intervention. Understanding the imaging findings of barium defecography in the spectrum of pathology of the anorectum and pelvic floor allows one to appropriately triage and treat patients presenting with defecatory dysfunction.

Management of Common Benign Anorectal Disease: What All Physicians Need to Know

Benign anorectal conditions produce anal pain, rectal bleeding, or discharge from the perianal region, which are highly prevalent symptoms in the general population. Hemorrhoidal disease, anal fissure, perianal abscess, proctalgia syndromes, and pruritus anii are the most common clinical disorders. Well-trained physicians, irrespective of their specialty, can treat most of these disorders and refer them to a specialist in proctology only when necessary. The aim of this review is to provide a practical guide to the management of benign anorectal disorders in terms of their initial management and the criteria for specialist referral.

Tricyclic antidepressants for the treatment of tenesmus associated with rectal prolapse

AIM

Tenesmus in rectal prolapse leads to a vicious circle of straining with deterioration of prolapse. The primary phenomenon triggering this may be rectal hypersensitivity. We aimed to assess whether treatment with tricyclic antidepressants (TCAs) may break the vicious circle and improve tenesmus.

METHOD

A retrospective review was carried out of patients with rectal prolapse and severe tenesmus who were poor surgical candidates or had refused surgery. They were treated at our tertiary centre with low dose tricyclic antidepressants.

RESULTS

Twenty-three (18 female) patients were included, with mean age 75.3 (±SD 14.6) years. The mean duration of symptoms was 10.8 (± 8.6) months. Full-thickness rectal prolapse was diagnosed in 16 (70%) patients while seven (30%) had mucosal or incomplete prolapse. Ten (43%), eight (35%) and five (22%) patients were treated with nortriptyline (25 mg daily), amitriptyline (10 mg daily) and desipramine (25 mg daily). After a mean follow-up of 9.05 (± 8.2) months, 14 (61%) patients reported significant improvement in symptoms, five (22%) had a partial response, three (13%) were lost to follow-up and one (4%) failed to respond. The response rates for nortriptyline, desipramine and amitriptyline were 90%, 100% and 62.5%.

CONCLUSION

To the best of our knowledge this is the first report to address the symptomatic, conservative treatment of tenesmus in patients with rectal prolapse. TCAs may be an acceptable option for poor surgical candidates or patients refusing surgery.

Defecating Disorders: A Common Cause of Constipation in Women

Defecating disorders are a common and complex problem. There are a range of anatomical and functional bowel abnormalities that can lead to this condition. Treatment is difficult and needs a multidisciplinary approach. First line treatment for defecating disorders is conservative. For those that fail conservative treatment, some may respond to surgical therapy but with variable results. The aim of this review is to offer an overview of defecating disorders as well as provide an algorithm on how to diagnose and treat them with the help of a multidisciplinary and multimodal approach.