Paradoxical puborectalis contraction and increased perineal descent

Ventral mesh rectopexy. Does a descending perineum impact functional results and quality of life?

PURPOSE

The impact of perineal descent (PD) on functional outcome and quality of life after ventral mesh rectopexy (VMR) is unknown. The purpose of this study was to analyze the effect of PD on the functional outcome and quality of life (QOL) after VMR.

METHODS

A retrospective analysis was performed on fifty-five patients who underwent robotic VMR between 2018 and 2021. Pre and postoperative data along with radiological studies were gathered from a prospectively maintained database. The Cleveland Clinic Constipation score (CCCS), the Rome IV criteria and the 36-Item Short-Form Health Survey (SF-36), were used to measure functional results and QOL.

RESULTS

All 55 patients (mean age 57.8 years) were female. Most patients had radiological findings of severe PD (n = 31) as opposed to mild/moderate PD (n = 24). CCCS significantly improved at 3 months and 1 year post-VMR (mean difference = -4.4 and -5.4 respectively, p < 0.001) with no significant difference between the two groups. The percentage of functional constipation Rome IV criteria only showed an improved outcome at 3 months for severe PD and at 1 year for mild/moderate PD (difference = -58.1% and -54.2% respectively, p < 0.05). Only the SF-36 subscale bodily pain significantly improved in the mild/moderate PD group (mean difference = 16.7, p = 0.002) 3 months post-VMR which subsided after one year (mean difference = 5.5, p = 0.068).

CONCLUSION

Severe PD may impact the functional outcome of constipation without an evident effect on QOL after VMR. The results, however, remain inconclusive and further research is warranted.

The Relevance of the Excessive Perineal Descent in the Obstructed Defecation Syndrome: A Prospective Study of 141 Patients

BACKGROUND

Despite the widely accepted association between excessive straining and perineal descent, the clinical significance of perineal descent in patients with obstructed defecation syndrome is still unclear.

OBJECTIVE

This study aimed to evaluate the prevalence of pathological perineal descent in patients with obstructed defecation syndrome and the impact of perineal descent on symptoms severity.

DESIGN

This was a prospective multicenter uncontrolled study.

SETTINGS

The study involved 3 hospital pelvic-care centers and was conducted from January 2018 to January 2022.

PATIENTS

The study included 141 consecutive adult patients with an obstructed defecation syndrome score of 9 or more and no evidence of organic GI pathology. All the patients underwent dynamic pelvic MRI and, in case of suspected paradoxical puborectalis contraction, anal manometry.

MAIN OUTCOME MEASURES

Main outcome measures were the prevalence of excessive perineal descent and the correlation between perineal descent and obstructed defecation syndrome score.

RESULTS

One hundred twenty-eight patients (90.7%) completed magnetic resonance examination and were included in the analysis. Of these, 18 patients (14.1%) had a physiological perineal descent and 110 (85.9%) had an excessive perineal descent. Excessive perineal descent was found in 46.1% of patients (12/26) with MRI signs of paradoxical puborectalis contraction and in 96% of patients (98/102) with normal puborectalis relaxation. In this latter group of patients, a good correlation between obstructed defecation syndrome score and maximum perineal descent during straining was found (Spearman r test: 0.68; p < 0.0001).

LIMITATIONS

The study was limited by the small sample size and by the strong selection of the study population.

CONCLUSIONS

Excessive perineal descent is a common finding in patients with obstructed defecation syndrome and high symptoms score, occurring almost consistently in patients without paradoxical puborectalis contraction. In these patients, the maximum perineal descent seems to be well correlated with symptoms severity. See Video Abstract at http://links.lww.com/DCR/C135 .

LA RELEVANCIA DEL DESCENSO PERINEAL EXCESIVO EN EL SNDROME DE DEFECACIN OBSTRUIDA UN ESTUDIO PROSPECTIVO DE PACIENTES

ANTECEDENTES:A pesar de la asociación ampliamente aceptada entre el esfuerzo excesivo y el descenso perineal, la importancia clínica del descenso perineal en pacientes con síndrome de defecación obstruida aún no está clara.OBJETIVO:Evaluar la prevalencia del descenso perineal patológico en pacientes con síndrome de defecación obstruida y el impacto del descenso perineal en la severidad de los síntomas.DISEÑO:Este fue un estudio prospectivo multicéntrico no controladoENTORNO CLINICO:El estudio involucró a tres centros hospitalarios de atención pélvica y se llevó a cabo entre enero de 2018 y enero de 2022.PACIENTES:El estudio incluyó a 141 pacientes adultos consecutivos con puntuación del síndrome de defecación obstruida ≥ 9 y sin evidencia de patología gastrointestinal orgánica. A todas las pacientes se les realizó resonancia magnética pélvica dinámica y, en caso de sospecha de contracción puborrectal paradójica, manometría anal.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado fueron la prevalencia del descenso perineal excesivo y la correlación entre el descenso perineal y la puntuación del síndrome de defecación obstruida.RESULTADOS:Ciento veintiocho (90,7%) pacientes completaron el examen de resonancia magnética y fueron incluidos en el análisis. De estos, 18 (14,1%) presentaron descenso perineal fisiológico y 110 (85,9%) descenso perineal excesivo. Se encontró descenso perineal excesivo en el 46,1% (12/26) de los pacientes con signos de contracción puborrectal paradójica en la resonancia magnética y en el 96% (98/102) de los pacientes con relajación puborrectal normal. En estos últimos pacientes se encontró una buena correlación entre la puntuación del síndrome de defecación obstruida y el descenso perineal máximo durante el esfuerzo (prueba r de Spearman: 0,68; p < 0,0001).LIMITACIONES:El estudio estuvo limitado por el pequeño tamaño de la muestra y por la fuerte selección de la población de estudio.CONCLUSIONES:El descenso perineal excesivo es un hallazgo común en pacientes con síndrome de defecación obstruida y alto puntaje de síntomas, ocurriendo casi constantemente en pacientes sin contracción puborrectal paradójica. En estos últimos pacientes el descenso perineal máximo parece estar bien correlacionado con la severidad de los síntomas. Consulte Video Resumen en http://links.lww.com/DCRC135 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

MR defecography in ano-rectal dysfunction: a clinical-radiological correlation study

Background

The aim of this work is to assess the diagnostic accuracy of MR defecography in ano-rectal dysfunction [ARD] for proper treatment planning.

Results

MR defecography was done to 30 patients with ARD for detection of its functional and structural causes. Increased perineal descent was detected in 70% of cases, rectocele in 46.7%, rectal intussusception in 40%, cystocele in 26.7%, uterine prolapse in 27.7%, enterocele in 13.3%, and paradoxical puborectalis contraction in 30%.

Conclusion

MR defecography is an essential diagnostic tool for optimum management of ano-rectal dysfunction patients.

Imaging of chronic male pelvic pain: what the abdominal imager should know

Chronic pelvic pain is an important but underrecognized cause of morbidity in men. While there is abundant literature discussing female pelvic pain and the diagnostic role of imaging, much less attention has been given to imaging of non-gynecologic causes of chronic pelvic pain. Chronic pelvic pain in men can be a challenge to diagnose as pain may arise from visceral, musculoskeletal, or neurovascular pathology. Imaging of the pelvic viscera has been covered in detail elsewhere in this edition and therefore will not be reviewed here. We will focus upon topics less familiar to the abdominal radiologist, including imaging of pelvic floor, musculoskeletal, and neurovascular pathology.

Anatomy, physiology, and updates on the clinical management of constipation

Clinical management of constipation has evolved from the prescription of dietary supplements, to potent stimulant laxatives, to corrective surgeries for organic blockage. Yet constipation does not respond to a one-size-fits-all treatment. In recent decades, the Bristol Stool Form Scale and Rome III diagnostic criteria have allowed for algorithmic diagnosis, yet these criteria could benefit from further extension and meaningful discussion. This review incorporates pertinent clinical updates and uses the anatomy and physiology of constipation as helpful signposts for the practicing clinician.

Clinical and manometric characteristics of women with paradoxical puborectalis syndrome

Background

A subset of patients with functional defecation disorders have predominance of the puborectalis muscle (PRM) on three-dimensional high definition anorectal manometry (HDARM), known as paradoxical puborectalis syndrome (PPS). The aim of this study was to assess clinical and manometric differences between patients with and without PPS.

Methods

A total of 227 women with functional defecation disorders undergoing HDARM between December 2012 and October 2016 at a single center were included in this study. All completed the Rome III constipation module and Pelvic Floor Distress Inventory 20 (PFDI-20).

Results

Eighty-seven out of 227 women had a 3D pressure topographic profile consistent with PPS. They had higher mean PDFI-20 scores for straining and incomplete evacuation symptoms than those without PPS. In addition, they demonstrated higher mean resting anal pressure, a more negative mean anorectal pressure differential, and a greater proportion with prolonged balloon expulsion test. These findings were more pronounced in a subgroup of 58 PPS patients with a distinct pattern of both posterior and posterolateral wall indentation.

Conclusion

Among female patients with functional defecation disorders, those with PPS demonstrated clinical and manometric differences compared to those without PPS. These differences may be driven by predominant posterolateral wall indentation in a subgroup of PPS patients.

Update on the Pathophysiology and Management of Anorectal Disorders

Anorectal disorders are common and present with overlapping symptoms. They include several disorders with both structural and functional dysfunction(s). Because symptoms alone are poor predictors of the underlying pathophysiology, a diagnosis should only be made after evaluating symptoms and physiologic and structural abnormalities. A detailed history, a thorough physical and digital rectal examination and a systematic evaluation with high resolution and/or high definition three-dimensional (3D) anorectal manometry, 3D anal ultrasonography, magnetic resonance defecography and neurophysiology tests are essential to correctly identify these conditions. These physiological and imaging tests play a key role in facilitating a precise diagnosis and in providing a better understanding of the pathophysiology and functional anatomy. In turn, this leads to better and more comprehensive management using medical, behavioral and surgical approaches. For example, patients presenting with difficult defecation may demonstrate dyssynergic defecation and will benefit from biofeedback therapy before considering surgical treatment of coexisting anomalies such as rectoceles or intussusception. Similarly, patients with significant rectal prolapse and pelvic floor dysfunction or patients with complex enteroceles and pelvic organ prolapse may benefit from combined behavioral and surgical approaches, including an open, laparoscopic, transabdominal or transanal, and/or robotic-assisted surgery. Here, we provide an update on the pathophysiology, diagnosis, and management of selected common anorectal disorders.

Successful Treatment of Paradoxical Puborectalis Contraction and Intractable Anorectal Pain With Sacral Neuromodulation

BACKGROUND

Paradoxical puborectalis contraction (PPC) is a syndrome of obstructed defecation associated with a cluster of complaints including rectal pain, incomplete evacuatory sensation, prolonged repetitive straining with bowel movements, and the need for digital manipulation. Traditional treatment has yielded mixed results.

CASE

We present a case of PPC successfully treated with staged sacral neuromodulation and review her diagnostic features, medical regimen, and prior unsuccessful interventions tried. Symptoms were analyzed using a visual analog scale pain score (0-10). Criteria to progress to implantation of the pulse generator included a pain score less than 3 during test stimulation and/or greater than 50% decrease in the pain score compared to baseline.Our patient had a pain score of 0 (baseline 8) with stage 1 sacral neuromodulation. In addition, she had dramatic relief in her straining with bowel movements and need for digital manipulation. Her pulse generator was implanted after a 2-week trial, and she has experienced a lasting improvement at her follow-up of 2 years.

CONCLUSIONS

Sacral neuromodulation is an established therapy for overactive bladder syndrome, urinary retention, and fecal incontinence. In urology, the use of sacral neuromodulation has been described to benefit some patients with pelvic floor pain. Sacral neuromodulation can be a successful treatment for PPC and functional anorectal pain with resulting improvement in quality of life without the sequelae of an invasive and irreversible surgery.

Functional Disorders of Constipation: Paradoxical Puborectalis Contraction and Increased Perineal Descent

Paradoxical puborectalis contraction (PPC) and increased perineal descent (IPD) are subclasses of obstructive defecation. Often these conditions coexist, which can make the evaluation, workup, and treatment difficult. After a thorough history and examination, workup begins with utilization of proven diagnostic modalities such as cinedefecography and anal manometry. Advancements in technology have increased the surgeon's diagnostic armamentarium. Biofeedback and pelvic floor therapy have proven efficacy for both conditions as first-line treatment. In circumstances where PPC is refractory to biofeedback therapy, botulinum toxin injection is recommended. Historically, pelvic floor repair has been met with suboptimal results. In IPD, surgical therapy now is directed toward the potentially attendant abnormalities such as rectoanal intussusception and rectal prolapse. When these associated abnormalities are not present, an ostomy should be considered in patients with IPD as well as medically refractory PPC.

A transanal procedure using TST STARR Plus for the treatment of Obstructed Defecation Syndrome: 'A mid-term study'

PURPOSE

The aim of this study was to assess the safety, efficacy and outcomes of TST STARR (Stapled Transanal Rectal Resection) plus to treat Obstructed Defecation Syndrome (ODS) at mid-term follow-up.

METHODS

From April 2013 to September 2014, 50 cases (7 male patients) with ODS caused by rectocele and/or internal rectal prolapse were treated with the new TST STARR Plus. Clinical data from the 18 month mid-term follow up, including efficacy and constipations were recorded.

RESULTS

The average duration of surgery was 21 ± 4 min (range 12-35 min). The average postoperative hospital stay was 5 days (range 4-8 days). The pathological findings showed that the specimens contained full-thickness rectal tissue in all patients. The mean volume of resected specimen was 12.3 cm(3). Postoperative complications included five cases with transient faecal urgency that dissipated after 3 months; one patient suffered anastomotic bleeding on the sixth day after surgery, with successful haemostasis achieved through conservative therapy. The Wexner constipation score improved in patients affected by ODS from 13.96 ± 2.37 preoperatively to 7.00 ± 3.90, 7.28 ± 3.91, 8.10 ± 4.05 and 8.44 ± 4.08 at 3,6,12 and 18 months postoperatively, respectively, with all p < 0.05. Overall outcome was reported as ''excellent'' in 42% of patients, ''good'' in 36% of patients, ''adequate'' in 12% of patients, and ''poor'' in 10% of patients after 18 months of follow-up.

CONCLUSIONS

The TST STARR Plus is a simple, safe, and effective option for selected patients with ODS. Long-term prospective clinical studies are needed to validate the advantages of this emerging, novel procedure.

MR Imaging in Diagnosis of Pelvic Floor Descent: Supine versus Sitting Position

Introduction. Functional disorders of the pelvic floor represent have a significant impact on the quality of life. The advent of open-configuration systems allowed for the evaluation of defecation with MR imaging in sitting position. The purpose of the present study is to compare the results of static and dynamic pelvic MR performed in supine position versus sitting position, using a new MR prototype machine, in the diagnosis of pelvic floor descent. Materials and Methods. Thirty-one patients with pelvic floor disorders were enrolled, and underwent MR Defecography in supine position with 1.5 T closed magnet (MAGNETOM Symphony, Siemens, Germany) and in sitting position with a 0.25-Tesla open magnet system (G-Scan ESAOTE, Italy). Results. In rest and squeezing phases, positions of bladder, vagina, and ARJ were significantly different when the patient was imaged in supine versus sitting position. In the defecation phase, a significant difference for the bladder and vagina position was detected between the two exams whereas a significant difference for the ARJ was not found. A statistically significant difference exists when the pelvic floor descent is evaluated in sitting versus supine position. Conclusion. Our results show that MR Defecography in sitting position may represent a useful tool to correctly diagnose and grade the pelvic organ descent.

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.

In the clinic. Constipation

This issue provides a clinical overview of constipation, focusing on prevention, diagnosis, treatment, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.

Is it really small-bowel obstruction in patients with paradox after IPAA?

BACKGROUND

Diagnosing outlet obstruction after IPAA can be challenging because the etiology is multifactorial.

OBJECTIVE

The aim of this study was to assess possible factors associated with outlet obstruction from paradoxical anal muscle contraction (paradox) after IPAA unrelated to strictures or structural abnormalities.

DESIGN

This was a retrospective study from a prospectively maintained pouch database.

SETTINGS

The study was conducted at a tertiary referral center.

PATIENTS

All of the patients with paradox after ileal J-pouch-anal anastomosis verified by anal physiology were identified from our prospectively maintained database. Patients with endoscopic or digital evidence of strictures or other anatomic abnormalities were excluded.

MAIN OUTCOME MEASURES

Demographic, clinical, and perioperative factors were obtained, including previous abdominal operations, history of pouchitis, need for anal intubation, diagnosis of small-bowel obstruction, and radiologic findings at the time of paradox diagnosis.

RESULTS

There were 40 patients (17 women) with an overall mean age of 39 years (range, 17-60 years) and a mean follow-up of 15 years (range, 1-28 years) after IPAA. Pathologic diagnoses at the time of ileal pouch creation were ulcerative colitis (n = 27), indeterminate colitis (n = 11), Crohn's disease, and familial adenomatous polyposis (1 case each). A total of 15 (37%) of 40 patients were diagnosed with small-bowel obstruction before their paradox diagnosis, 8 of whom underwent surgery, which revealed diffusely dilated small bowel and pouch without intraoperative identification of a transition point. The time from ileal pouch creation to paradox diagnosis was significantly longer in patients receiving a diagnosis of small-bowel obstruction than in the remaining paradox patients (7.2 vs 2.6 years; p < 0.001).

LIMITATIONS

This study was limited by its nonrandomized retrospective nature.

CONCLUSIONS

After an IPAA, patients with outlet obstruction from paradox can appear to have a small-bowel obstruction. A high incidence of suspicion is needed to make the correct diagnosis and avoid an unneeded laparotomy.

The effect of biofeedback therapy on dyssynergic constipation in patients with or without Irritable Bowel Syndrome

BACKGROUND

The Rome II and III diagnostic criteria for dyssynergic defecation recommended the exclusion of irritable bowel syndrome (IBS). This study determined the effect of biofeedback therapy on dyssynergic constipation in patients with or without IBS.

MATERIALS AND METHODS

This study was a nonrandomized, single blinded, semi experimental study. Dyssynergic defecation patients with and without IBS were asked to undergo biofeedback therapy 8 sessions. The defecation dynamics and balloon expulsion time were evaluated before, at the end and 1 month after the biofeedback therapy. IBS symptoms were graded using a 4-point Likert scale. Mann-Whitney U-test, Wilcoxon test and Friedman test were applied to analyze data using SPSS software package (SPSS Inc., Chicago, IL, USA).

RESULTS

After the biofeedback therapy, the IBS symptoms have been decreased significantly (the median of 2 before and 1 after therapy, P < 0.01). The biofeedback therapy significantly decreased the anismus index in IBS group by the mean of 0.75 ± 0.31, 0.28 ± 0.07 and 0.28 ± 0.06 in three phases, respectively. Similar results were found in non-IBS patients (the mean of 0.74 ± 0.32, 0.28 ± 0.08, 0.27 ± 0.08 in three phases, respectively). The symptoms of constipation (sensation of incomplete evacuation, difficult and painful defecation), defecation facilitative manual maneuver frequency, pelvic floor muscles resting amplitude and strain amplitude decreased and squeezing amplitude improved significantly after biofeedback therapy in both groups with and without IBS (P < 0.001). There were not significant differences between patients with and without IBS (P > 0.05) with respect to outcome. No complication was observed in treatment groups.

CONCLUSION

Dyssynergic constipation patients with and without IBS will likely benefit from biofeedback therapy.

Three-dimensional high-resolution anorectal manometry in the diagnosis of paradoxical puborectalis syndrome compared with healthy adults: a retrospective study in 79 cases

OBJECTIVES

The aim of this study is to evaluate the three-dimensional anorectal pressure topography of normal healthy adults and patients with paradoxical puborectalis syndrome (PPS) using a novel three-dimensional high-resolution manometry (3D-HRM) of the anorectum.

METHODS

The 3D-HRM probe has a 6.4 cm long sensing segment that is composed of 256 independent pressure transducers around its circumference. It generates a 3D pressure topographic profile of the anorectum. We evaluated 41 women and 38 men with PPS (median age 52 years), and compared them with 37 women and 34 men who were healthy (median age 51 years). The three-dimensional anorectal pressure topography was evaluated at rest, and during squeeze, stimulated defecation, and balloon inflation.

RESULTS

Maximum resting pressure, mean resting pressure, high pressure zone length, and residual anal pressure were significantly higher in patients with PPS compared with healthy adults (P<0.01 each). The rectoanal pressure differential was significantly lower in the PPS patients compared with healthy adults (P<0.05). There was a characteristic purple high-pressure area in the posterior wall of the pressure cylinder of patients with PPS during stimulated defecation that was absent in healthy adults. The longest diameter and widest diameter of this purple high-pressure area were 1.71 ± 0.25 and 1.07 ± 0.14 cm. The maximum, mean, and minimum pressures of the posterior distal pressure zone were significantly higher in patients with PPS (270.1 ± 8.2, 152.7 ± 4.8, and 51.9 ± 2.7 mmHg, respectively) compared with healthy adults (168.5 ± 11.1, 88.0 ± 5.9, and 30.7 ± 2.8 mmHg, respectively) (P<0.01).

CONCLUSION

Using the 3D-HRM technique, the increase in the resting pressure and residual anal pressure and decrease in the rectoanal pressure differential in patients with PPS compared with healthy adults further indicated the mechanism of this disease. Unlike traditional manometry, the 3D-HRM technique could find, locate, and evaluate the scope and the pressure of the paradoxical contraction of puborectalis muscle, which further indicates the value of manometry in terms of diagnosis.

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.

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.

Colorectal and uterine movement and tension of the inferior hypogastric plexus in cadavers

BACKGROUND

Hypotheses on somatovisceral dysfunction often assume interference by stretch or compression of the nerve supply to visceral structures. The purpose of this study is to examine the potential of pelvic visceral movement to create tension of the loose connective tissue that contains the fine branches of the inferior hypogastric nerve plexus.

METHODS

Twenty eight embalmed human cadavers were examined. Pelvic visceral structures were displaced by very gentle 5 N unidirectional tension and the associated movement of the endopelvic fascia containing the inferior hypogastric plexus that this caused was measured.

RESULTS

Most movement of the fascia containing the inferior hypogastric plexus was obtained by pulling the rectosigmoid junction or broad ligament of the uterus. The plexus did not cross any vertebral joints and the fascia containing it did not move on pulling the hypogastric nerve.

CONCLUSIONS

Uterine and rectosigmoid displacement produce most movement of the fascia containing the hypogastric nerve plexus, potentially resulting in nerve tension. In the living this might occur as a consequence of menstruation, pregnancy or constipation. This may be relevant to somatovisceral reflex theories of the effects of manual therapy on visceral conditions.

A transanal procedure using an endoscopic linear stapler for obstructed defecation syndrome: the first Chinese experience

BACKGROUND

Transanal surgery using an endoscopic linear stapler is a recognized, but not widely performed technique for the treatment of obstructed defecation syndrome (ODS). A study of consecutive patients was conducted to evaluate the safety and effectiveness of the technique for the treatment of ODS in Chinese patients.

METHODS

From November 2008 to December 2010, 43 female patients with ODS caused by rectocele and/or rectal intussusception underwent transanal surgery using an endoscopic linear stapler in three Chinese hospitals. Clinical and functional data including the Wexner constipation score and outcome classification were analyzed retrospectively.

RESULTS

The average duration of surgery was 23 ± 4 min (range 15-30 min). Blood loss was 10 ± 2 ml (range 5-15 ml). The average postoperative hospital stay was 5 days (range 4-6 days). The pathologic findings showed that the specimen contained rectal muscle in all patients. Postoperative complications included 4 patients with transient fecal urgency, 3 patients with anorectal pain, and one patient with mild bleeding from the stapled suture line. Three patients reported minor fecal incontinence (Wexner score less than 3). During a median follow-up of 12 months (range, 3-26 months), the mean constipation score improved from preoperative 13.56 to postoperative 5.07 at 1 year (P < 0.05). The outcome at 1 year was excellent in 18 of 43 patients, good in 13, fairly good in 7, and poor in 5. Postoperative defecography was performed in 28 patients. Rectocele disappeared in 15 patients. Rectocele depth was reduced from 34 ± 4 mm preoperatively to 17 ± 3 mm postoperatively (P < 0.05).

CONCLUSION

The transanal procedure using an endoscopic linear stapler is an easy, safe, and effective option for selected patients with ODS. Long-term prospective, randomized, controlled studies are needed to confirm the advantages of this procedure in comparison with the traditional transanal and stapled transanal rectal resection (STARR) techniques.