Patients' perception of tests in the assessment of faecal incontinence

Perceived patient burden and acceptability of MRI in comparison to PSA and ultrasound: results from the IP1-PROSTAGRAM study

BACKGROUND

The IP1-PROSTAGRAM study showed that a short, non-contrast MRI detected more significant cancers with similar rates of biopsy compared to PSA. Herein, we compare the expected and perceived burden of PSA, MRI and ultrasound as screening tests.

METHODS

IP1-PROSTAGRAM was a prospective, population-based, paired screening study of 408 men conducted at seven UK primary care practices and two imaging centres. The screening tests were serum PSA, non-contrast MRI and ultrasound. If any test was screen-positive, a prostate biopsy was performed. Participants completed an Expected Burden Questionnaire (EBQ) and Perceived Burden Questionnaire (PBQ) before and after each screening test.

RESULTS

The overall level of burden for MRI and PSA was minimal. Few men reported high levels of anxiety, burden, embarrassment or pain following either MRI or PSA. Participants indicated an overall preference for MRI after completing all screening tests. Of 408 participants, 194 (47.5%) had no preference, 106 (26.0%) preferred MRI and 79 (19.4%) preferred PSA. This indicates that prior to screening, participants preferred MRI compared to PSA (+6.6%, 95% CI 4.4-8.4, p = 0.02) and after completing screening, the preference for MRI was higher (+21.1%, 95% CI 14.9-27.1, p < 0.001). The proportion of participants who strongly agreed with repeating the test was 50.5% for ultrasound, 65% for MRI and 68% for PSA. A larger proportion of participants found ultrasound anxiety-inducing, burdensome, embarrassing and painful compared to both MRI and PSA.

CONCLUSIONS

Prostagram MRI and PSA are both acceptable as screening tests among men aged 50-69 years. Both tests were associated with minimal amounts of anxiety, burden, embarrassment and pain. The majority of participants preferred MRI over PSA and ultrasound.

REGISTRATION

This study was registered on clinicaltrials.gov at https://clinicaltrials.gov/ct2/show/NCT03702439 .

Rectocele: Correlation Between Defecography and Physical Examination

IMPORTANCE

There is a lack of consensus regarding the clinical applicability of fluoroscopic defecography in evaluation of pelvic organ prolapse.

OBJECTIVES

The aim was to evaluate the association between rectocele on defecography and posterior vaginal wall prolapse (PVWP) on physical examination. The secondary objective was to describe radiologic and clinical predictors of surgical intervention and outcomes.

STUDY DESIGN

This was a retrospective review of patients enrolled in a large health maintenance organization who underwent defecography and were examined by a urogynecologist within 12 months. The electronic medical record was reviewed for demographic and clinical variables, including pelvic organ prolapse and defecatory symptoms, physical examination, and surgical intervention through 12 months after initial urogynecologic examination or 12 months after surgery if applicable.

RESULTS

One hundred eighty-six patients met inclusion criteria. Of those, 168 (90.3%) had a rectocele on defecography and 31 (16.6%) had PVWP at or beyond the hymen. Rectocele size on defecography was poorly correlated with PVWP stage (spearman ρ = 0.18). Forty patients underwent surgical intervention. Symptoms of splinting, digitation, and stool trapping were associated with surgical intervention (odds ratio, 4.24; 95% confidence interval, 1.59-11.34; P < 0.01) as was advanced PVWP stage ( P < 0.01), while rectocele presence and size on defecography were not. Large rectocele size on defecography was correlated with persistent postoperative defecatory symptoms ( P = 0.02).

CONCLUSIONS

We demonstrated a poor correlation between rectocele size on defecography and PVWP stage. Defecatory symptoms (splinting, digitation, stool trapping) and higher PVWP stage were associated with surgical intervention, while rectocele on defecography was not.

MR defecography technique: recommendations of the society of abdominal radiology's disease-focused panel on pelvic floor imaging

PURPOSE

To develop recommendations for magnetic resonance (MR) defecography technique based on consensus of expert radiologists on the disease-focused panel of the Society of Abdominal Radiology (SAR).

METHODS

An extensive questionnaire was sent to a group of 20 experts from the disease-focused panel of the SAR. The questionnaire encompassed details of technique and MRI protocol used for evaluating pelvic floor disorders. 75% agreement on questionnaire responses was defined as consensus.

RESULTS

The expert panel reached consensus for 70% of the items and provided the basis of these recommendations for MR defecography technique. There was unanimous agreement that patients should receive coaching and explanation of commands used during MR defecography, the rectum should be distended with contrast agent, and that sagittal T2-weighted images should include the entire pelvis within the field of view. The panel also agreed unanimously that IV contrast should not be used for MR defecography. Additional areas of consensus ranged in agreement from 75 to 92%.

CONCLUSION

We provide a set of consensus recommendations for MR defecography technique based on a survey of expert radiologists in the SAR pelvic floor dysfunction disease-focused panel. These recommendations can be used to develop a standardized imaging protocol.

Japanese Practice Guidelines for Fecal Incontinence Part 2-Examination and Conservative Treatment for Fecal Incontinence- English Version

Examination for fecal incontinence is performed in order to evaluate the condition of each patient. As there is no single method that perfectly assesses this condition, there are several tests that need to be conducted. These are as follows: anal manometry, recto anal sensitivity test, pudendal nerve terminal motor latency, electromyogram, anal endosonography, pelvic magnetic resonance imaging (MRI) scan, and defecography. In addition, the mental and physical stress most patients experience during all these examinations needs to be taken into consideration. Although some of these examinations mostly apply for patients with constipation, we hereby describe these tests as tools for the assessment of fecal incontinence. Conservative therapies for fecal incontinence include diet, lifestyle, and bowel habit modification, pharmacotherapy, pelvic floor muscle training, biofeedback therapy, anal insert device, trans anal irrigation, and so on. These interventions have been identified to improve the symptoms of fecal incontinence by determining the mechanisms resulting in firmer stool consistency; strengthening the pelvic floor muscles, including the external anal sphincter; normalizing the rectal sensation; or periodic emptying of the colon and rectum. Among these interventions, diet, lifestyle, and bowel habit modifications and pharmacotherapy can be performed with some degree of knowledge and experience. These two therapies, therefore, can be conducted by all physicians, including general practitioners and other physicians not specializing in fecal incontinence. However, patients with fecal incontinence who did not improve following these initial therapies should be referred to specialized institutions. Contrary to the initial therapies, specialized therapies, including pelvic floor muscle training, biofeedback therapy, anal insert device, and trans anal irrigation, should be conducted in specialized institutions as these require patient education and instructions based on expert knowledge and experience. In general, conservative therapies should be performed for fecal incontinence before surgery because its pathophysiologies are mostly attributed to benign conditions. All Japanese healthcare professionals who take care of patients with fecal incontinence are expected to understand the characteristics of each conservative therapy, so that appropriate therapies will be selected and performed. Therefore, in this chapter, the characteristics of each conservative therapy for fecal incontinence are described.

Patient perspectives on repeated MRI and PET/CT examinations during neoadjuvant treatment of esophageal cancer

OBJECTIVE

The perceived burden of diagnostic tests by patients during the assessment of esophageal cancer warrants attention with the current increase in repeated imaging for purposes of disease monitoring during and after treatment. The purpose of this prospective study was to evaluate the experienced burden associated with repeated MRI and positron emission tomography with integrated CT (PET/CT) examinations during neoadjuvant treatment for esophageal cancer from the perspective of the patient.

METHODS

In 27 patients receiving neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer MRI and PET/CT examinations were performed before nCRT, during nCRT and before surgery. The experienced burden during repeated MRI and PET/CT examinations was evaluated with a self-report questionnaire addressing discomfort, pain, anxiety and embarrassment, each measured on a 5-point Likert scale (1 = none; up to 5 = very much). In addition, a comparative assessment was used to rank MRI, PET/CT and baseline endoscopy.

RESULTS

All scans were performed without the occurrence of an adverse event. Few patients experienced discomfort (mean score ±SD: 1.9 ± 1.0 for MRI vs 2.0 ± 1.0 for PET/CT, p = 0.586), pain (1.1 ± 0.4 for MRI vs 1.3 ± 0.7 for PET/CT, p = 0.059), anxiety (1.0 ± 0.2 for MRI vs 1.0 ± 0.2 for PET/CT, p = 1.000) and embarrassment (1.0 ± 0 for MRI vs 1.0 ± 0.2 for PET/CT, p = 0.317) during both MRI and PET/CT. Patients preferred MRI over PET/CT (67% vs 22%, respectively, p = 0.023), and MRI over endoscopy (59% vs 19%, respectively, p = 0.027). In the comparison between PET/CT and endoscopy, 59% of patients preferred PET/CT and 26% preferred endoscopy (p = 0.093).

CONCLUSION

Repeated imaging with both MRI and PET/CT is generally well-tolerated for the assessment of response to treatment in esophageal cancer patients. Shorter acquisition times and altered body positioning during scanning will likely improve patient experience. Advances in knowledge: This paper demonstrates that MRI and PET/CT are generally well-tolerated imaging procedures for the assessment of response to treatment in esophageal cancer patients. When asked to rank different tests, patients preferred MRI over PET/CT and endoscopy.

Electromagnetic-Guided Bedside Placement of Nasoenteral Feeding Tubes by Nurses Is Non-Inferior to Endoscopic Placement by Gastroenterologists: A Multicenter Randomized Controlled Trial

OBJECTIVES

Electromagnetic (EM)-guided bedside placement of nasoenteral feeding tubes by nurses may improve efficiency and reduce patient discomfort and costs compared with endoscopic placement by gastroenterologists. However, evidence supporting this task shift from gastroenterologists to nurses is limited. We aimed to compare the effectiveness of EM-guided and endoscopic nasoenteral feeding tube placement.

METHODS

We performed a multicenter randomized controlled non-inferiority trial in 154 adult patients who required nasoenteral feeding and were admitted to gastrointestinal surgical wards in five Dutch hospitals. Patients were randomly assigned (1:1) to undergo EM-guided or endoscopic nasoenteral feeding tube placement. The primary end point was the need for reinsertion of the feeding tube (e.g., after failed initial placement or owing to tube-related complications) with a prespecified non-inferiority margin of 10%.

RESULTS

Reinsertion was required in 29 (36%) of the 80 patients in the EM-guided group and 31 (42%) of the 74 patients in the endoscopy group (absolute risk difference -6%, upper limit of one-sided 95% confidence interval 7%; P for non-inferiority=0.022). No differences were noted in success and complication rates. In the EM-guided group, there was a reduced time to start of feeding (424 vs. 535 min, P=0.001). Although the level of discomfort was higher in the EM-guided group (Visual Analog Scale (VAS) 3.9 vs. 2.0, P=0.009), EM-guided placement received higher recommendation scores (VAS 8.2 vs. 5.5, P=0.008).

CONCLUSIONS

EM-guided bedside placement of nasoenteral feeding tubes by nurses was non-inferior to endoscopic placement by gastroenterologists in surgical patients and may be considered the preferred technique for nasoenteral feeding tube placement.

Burden of waiting for surveillance CT colonography in patients with screen-detected 6-9 mm polyps

Purpose

We assessed the burden of waiting for surveillance CT colonography (CTC) performed in patients having 6–9 mm colorectal polyps on primary screening CTC. Additionally, we compared the burden of primary and surveillance CTC.

Materials and methods

In an invitational population-based CTC screening trial, 101 persons were diagnosed with <3 polyps 6–9 mm, for which surveillance CTC after 3 years was advised. Validated questionnaires regarding expected and perceived burden (5-point Likert scales) were completed before and after index and surveillance CTC, also including items on burden of waiting for surveillance CTC. McNemar’s test was used for comparison after dichotomization.

Results

Seventy-eight (77 %) of 101 invitees underwent surveillance CTC, of which 66 (85 %) completed the expected and 62 (79 %) the perceived burden questionnaire. The majority of participants (73 %) reported the experience of waiting for surveillance CTC as ‘never’ or ‘only sometimes’ burdensome. There was almost no difference in expected and perceived burden between surveillance and index CTC. Waiting for the results after the procedure was significantly more burdensome for surveillance CTC than for index CTC (23 vs. 8 %; p = 0.012).

Conclusion

Waiting for surveillance CTC after primary CTC screening caused little or no burden for surveillance participants. In general, the burden of surveillance and index CTC were comparable.

Key points

• Waiting for surveillance CTC within a CRC screening caused little burden

• The vast majority never or only sometimes thought about their polyp(s)

• In general, the burden of index and surveillance CTC were comparable

• Awaiting results was more burdensome for surveillance than for index CTC

Electromagnetic guided bedside or endoscopic placement of nasoenteral feeding tubes in surgical patients (CORE trial): study protocol for a randomized controlled trial

Background

Gastroparesis is common in surgical patients and frequently leads to the need for enteral tube feeding. Nasoenteral feeding tubes are usually placed endoscopically by gastroenterologists, but this procedure is relatively cumbersome for patients and labor-intensive for hospital staff. Electromagnetic (EM) guided bedside placement of nasoenteral feeding tubes by nurses may reduce patient discomfort, workload and costs, but randomized studies are lacking, especially in surgical patients. We hypothesize that EM guided bedside placement of nasoenteral feeding tubes is at least as effective as endoscopic placement in surgical patients, at lower costs.

Methods/Design

The CORE trial is an investigator-initiated, parallel-group, pragmatic, multicenter randomized controlled non-inferiority trial. A total of 154 patients admitted to gastrointestinal surgical wards in five hospitals, requiring nasoenteral feeding, will be randomly allocated to undergo EM guided or endoscopic nasoenteral feeding tube placement. Primary outcome is reinsertion of the feeding tube, defined as the insertion of an endoscope or tube in the nose/mouth and esophagus for (re)placement of the feeding tube (e.g. after failed initial placement or dislodgement or blockage of the tube). Secondary outcomes include patient-reported outcomes, costs and tube (placement) related complications.

Discussion

The CORE trial is designed to generate evidence on the effectiveness of EM guided placement of nasoenteral feeding tubes in surgical patients and the impact on costs as compared to endoscopic placement. The trial potentially offers a strong argument for wider implementation of this technique as method of choice for placement of nasoenteral feeding tubes.

Trial registration

Dutch Trial Register: NTR4420, date registered 5-feb-2014

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0633-1) contains supplementary material, which is available to authorized users.

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.

Informed decision-making in colorectal cancer screening using colonoscopy or CT-colonography

OBJECTIVE

To evaluate the level of informed decision making in a randomized controlled trial comparing colonoscopy and CT-colonography for colorectal cancer screening.

METHODS

8844 citizens aged 50-75 were randomly invited to colonoscopy (n=5924) or CT-colonography (n=2920) screening. All invitees received an information leaflet. Screenees received a questionnaire within 4 weeks before the planned examination, non-screenees 4 weeks after the invitation. A decision was categorized as informed when characterized by sufficient decision-relevant knowledge and consistent with personal attitudes toward participation in screening.

RESULTS

Knowledge and attitude items were completed by 1032/1276 colonoscopy screenees (81%), by 698/4648 colonoscopy non-screenees (15%), by 824/982 CT-colonography screenees (84%) and by 192/1938 CT-colonography non-screenees (10%). 1027 colonoscopy screenees (>99%) and 815 CT-colonography screenees (99%) had adequate knowledge; 915 (89%) and 742 (90%) had a positive attitude. 675 non-screenees invited to colonoscopy (97%) and 182 invited to CT-colonography (95%) had adequate knowledge; 344 (49%) and 94 (49%) expressed a negative attitude.

CONCLUSION

A large majority of screenees made an informed decision on participation. Almost half of responding non-screenees, made an uninformed decision, suggesting additional barriers to participation.

PRACTICE IMPLICATIONS

Efforts to understand the additional barriers will create opportunities to facilitate informed participation to colorectal cancer screening.

Older peoples' perception of tests used in the assessment and management of COPD and asthma

OBJECTIVES

Outcome assessment is an important part of the management of airways disease, yet older adults may have difficulty with the burden of testing. This study evaluated the patient perception of tests used for the assessment of airways disease in older people.

DATA SOURCE

Older adults (>55 years) with obstructive airway disease and healthy controls (N = 56) underwent inhaler technique assessment, skin allergy testing, venepuncture, fractional exhaled nitric oxide (FENO) and gas diffusion measurement, exercise testing, sputum induction, and questionnaire assessment. They then completed an assessment burden questionnaire across five domains: difficulty, discomfort, pain, symptoms and test duration.

RESULTS

Test perception was generally favourable. Induced sputum had the greatest test burden perceived as being more difficult (mean 0.83, P = 0.001), associated with more discomfort (mean 1.3, P < 0.001), more painful (0.46, P = 0.019), longer test duration (0.84, P < 0.001) and worsening symptoms (0.55, P = 0.001) than the questionnaires. FENO had a more favourable assessment but was assessed to be difficult to perform. Inhaler technique received the most favourable assessment.

CONCLUSIONS

Older adults hold favourable perceptions to a range of tests that they might encounter in the course of their care for airway disease. The newer tests of sputum induction and FENO have some observed difficulties, in particular sputum induction. The results of this study can inform current practice by including details of the test and its associated adverse effects when conducting the test, as well as providing clear explanations of the utility of tests and how the results might aid in patient care.

Face-to-face vs telephone pre-colonoscopy consultation in colorectal cancer screening; a randomised trial

Background:

A pre-colonoscopy consultation in colorectal cancer (CRC) screening is necessary to assess a screenee’s general health status and to explain benefits and risks of screening. The first option allows for personal attention, whereas a telephone consultation does not require travelling. We hypothesised that a telephone consultation would lead to higher response and participation in CRC screening compared with a face-to-face consultation.

Methods:

A total of 6600 persons (50–75 years) were 1 : 1 randomised for primary colonoscopy screening with a pre-colonoscopy consultation either face-to-face or by telephone. In both arms, we counted the number of invitees who attended a pre-colonoscopy consultation (response) and the number of those who subsequently attended colonoscopy (participation), relative to the number invited for screening. A questionnaire regarding satisfaction with the consultation and expected burden of the colonoscopy (scored on five-point rating scales) was sent to invitees. Besides, a questionnaire to assess the perceived burden of colonoscopy was sent to participants, 14 days after the procedure.

Results:

In all, 3302 invitees were allocated to the telephone group and 3298 to the face-to-face group, of which 794 (24%) attended a telephone consultation and 822 (25%) a face-to-face consultation (P=0.41). Subsequently, 674 (20%) participants in the telephone group and 752 (23%) in the face-to-face group attended colonoscopy (P=0.018). Invitees and responders in the telephone group expected the bowel preparation to be more painful than those in the face-to-face group while perceived burden scores for the full screening procedure were comparable. More subjects in the face-to-face group than in the telephone group were satisfied by the consultation in general: (99.8% vs 98.5%, P=0.014).

Conclusion:

Using a telephone rather than a face-to-face consultation in a population-based CRC colonoscopy screening programme leads to similar response rates but significantly lower colonoscopy participation.

Measurements of pelvic floor dyssynergia: which test result matters?

PURPOSE

Failure to expel a 60-mL balloon on manometry and abnormal relaxation of anal sphincter on electromyographic testing are frequently used to diagnose pelvic floor dyssynergia. However, the relationship between these 2 test results and their relationship to defecography is poorly characterized. We aimed to describe this relationship and create a predictive model for pelvic floor dyssynergia on defecography.

METHODS

From March 2008 to April 2010 consecutive patients with symptoms suggestive of functional constipation were evaluated at our Pelvic Floor Disorders Center 125 and the results of their workups were collected prospectively. Sixty-three patients with pelvic floor dyssynergia on defecography were compared with 60 patients without dyssynergia in terms of manometry pressures, electromyographic text results, and balloon expulsion testing results (χ, t tests).

RESULTS

Of 125 patients meeting Rome II symptom criteria for constipation, 123 patients underwent defecography and, of these, 63 (51.2%) had evidence of pelvic floor dyssynergia. Patients with and without dyssynergia had a slight difference in mean resting pressures (62.8 mmHg vs 49.5 mmHg, P = .02) and no discernable differences in rectal sensitivity and compliance: first sensation (56.5 vs 62.5, P = .34) and maximum tolerated volume (164.2 vs 191.2, P = .09). It appeared that abnormalities in electromyographic relaxation and balloon expulsion occurred in the same patients: 84.1% of patients with abnormal electromyographic results also did not expel the balloon. However, the presence of these abnormalities, in isolation or together, did not predict the presence of dyssynergia on defecography.

CONCLUSION

Normal electromyographic results or the ability to expel a 60-mL balloon does not exclude the presence of pelvic floor dyssynergia on defecography. It is unclear which of these 3 tests should be used to guide the recommendation for (and to then measure response to) biofeedback.

Study protocol: population screening for colorectal cancer by colonoscopy or CT colonography: a randomized controlled trial

Background

Colorectal cancer (CRC) is the second most prevalent type of cancer in Europe. Early detection and removal of CRC or its precursor lesions by population screening can reduce mortality. Colonoscopy and computed tomography colonography (CT colonography) are highly accurate exams and screening options that examine the entire colon. The success of screening depends on the participation rate. We designed a randomized trial to compare the uptake, yield and costs of direct colonoscopy population screening, using either a telephone consultation or a consultation at the outpatient clinic, versus CT colonography first, with colonoscopy in CT colonography positives.

Methods and design

7,500 persons between 50 and 75 years will be randomly selected from the electronic database of the municipal administration registration and will receive an invitation to participate in either CT colonography (2,500 persons) or colonoscopy (5,000 persons) screening. Those invited for colonoscopy screening will be randomized to a prior consultation either by telephone or a visit at the outpatient clinic. All CT colonography invitees will have a prior consultation by telephone. Invitees are instructed to consult their general practitioner and not to participate in screening if they have symptoms suggestive for CRC. After providing informed consent, participants will be scheduled for the screening procedure. The primary outcome measure of this study is the participation rate. Secondary outcomes are the diagnostic yield, the expected and perceived burden of the screening test, level of informed choice and cost-effectiveness of both screening methods.

Discussion

This study will provide further evidence to enable decision making in population screening for colorectal cancer.

Trial registration

Dutch trial register: NTR1829

Imaging pelvic floor dysfunction

Pelvic floor function and structure are complex, and imaging (integrated with an understanding of physiology) is central to guiding the clinician in managing patients with incontinence, constipation, difficult rectal evacuation and pelvic organ prolapse. Multimodal imaging techniques such as static and dynamic imaging techniques (sometimes combined in a single sitting) have revolutionised our understanding of functional anatomy. The advent of endo-luminal imaging has increased our spatial resolution by its closer proximity to the area of interest. Dynamic imaging gives us a near physiological data set which helps us to simulate what is likely to happen in real life and gives us a better understanding of the multifactorial causes, and consequences, of pelvic floor dysfunction.

[Role of defecography in female posterior pelvic floor abnormalities]

Pelvic floor abnormalities often impact significantly the quality of life and result in a variety of symptoms, including chronic pelvic pain, fecal incontinence, and obstructed constipation. Fluoroscopic defecography and MR defecography enable identification of rectocele, rectal prolapse, enterocele, sigmoidocele with high prevalence in female patients with obstructed constipation, fecal incontinence, and chronic pelvic pain. In this manuscript, we describe the techniques and indications of the two techniques of defecography. We discuss the abnormalities of the posterior pelvic floor compartment at the origin of constipation, incontinence, chronic pelvic pain. Finally we compare the data obtained by clinical examination and defecography, remembering that 50% of enterocele and 100% of sigmoidocele are missed at clinical examination.