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

An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment

INTRODUCTION

The terminology for female and male pelvic floor muscle (PFM) assessment has expanded considerably since the first PFM function and dysfunction standardization of terminology document in 2005. New terms have entered assessment reports, and new investigations to measure PFM function and dysfunction have been developed. An update of this terminology was required to comprehensively document the terms and their definitions, and to describe the assessment method and interpretation of the finding, to standardize assessment procedures and aid diagnostic decision making.

METHODS

This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) Working Group 16, with contributions from recognized experts in the field and external referees. A logical, sequential, clinically directed assessment framework was created against which the assessment process was mapped. Within categories and subclassifications, each term was assigned a numeric coding. A transparent process of 12 rounds of full working group and external review was undertaken to exhaustively examine each definition, plus additional extensive internal development, with decision making by collective opinion (consensus).

RESULTS

A Terminology Report for the symptoms, signs, investigations, and diagnoses associated with PFM function and dysfunction, encompassing 185 separate definitions/descriptors, has been developed. It is clinically based with the most common assessment processes defined. Clarity and user-friendliness have been key aims to make it interpretable by clinicians and researchers of different disciplines.

CONCLUSION

A consensus-based Terminology Report for assessment of PFM function and dysfunction has been produced to aid clinical practice and be a stimulus for research.

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.

Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review

BACKGROUND

Fecal incontinence is a disabling condition affecting up to 20% of women.

OBJECTIVE

We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials.

METHODS

We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019.

RESULTS

In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies.

CONCLUSION

Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.

MRI of the Male Pelvic Floor

The pelvic floor is a complex structure that supports the pelvic organs and provides resting tone and voluntary control of the urethral and anal sphincters. Dysfunction of or injury to the pelvic floor can lead to gastrointestinal, urinary, and sexual dysfunction. The prevalence of pelvic floor disorders is much lower in men than in women, and because of this, the majority of the published literature pertaining to MRI of the pelvic floor is oriented toward evaluation of the female pelvic floor. The male pelvic floor has sex-specific differences in anatomy and pathophysiologic disorders. Despite these differences, static and dynamic MRI features of these disorders, specifically gastrointestinal disorders, are similar in both sexes. MRI and MR defecography can be used to evaluate anorectal disorders related to the pelvic floor. MRI can also be used after prostatectomy to help predict the risk of postsurgical incontinence, to evaluate postsurgical function by using dynamic voiding MR cystourethrography, and subsequently, to assess causes of incontinence treatment failure. Increased tone of the pelvic musculature in men secondary to chronic pain can lead to sexual dysfunction. This article reviews normal male pelvic floor anatomy and how it differs from the female pelvis; MRI techniques for imaging the male pelvis; and urinary, gastrointestinal, and sexual conditions related to abnormalities of pelvic floor structures in men.Online supplemental material is available for this article.^©RSNA, 2019.

The clinical value of magnetic resonance defecography in males with obstructed defecation syndrome

BACKGROUND

The aim of the present study was to assess the relationship between symptoms of obstructed defecation and findings on magnetic resonance (MR) defecography in males with obstructed defecation syndrome (ODS).

METHODS

Thirty-six males with ODS who underwent MR defecography at our institution between March 2013 and February 2016 were asked in a telephone interview about their symptoms and subsequent treatment, either medical or surgical. Patients were divided into 2 groups, one with anismus (Group 1) and one with prolapse without anismus (Group 2). The interaction between ODS type and symptoms with MR findings was assessed by multivariate analysis for categorical data using a hierarchical log-linear model. MR imaging findings included lateral and/or posterior rectocele, rectal prolapse, intussusception, ballooning of levator hiatus with impingement of pelvic organs and dyskinetic puborectalis muscle.

RESULTS

There were 21 males with ODS due to anismus (Group 1) and 15 with ODS due to rectal prolapse/intussusception (Group 2). Mean age of the entire group was 53.6 ± 4.1 years (range 18-77 years). Patients in Group 1 were slightly older than those in Group 2 (age peak, sixth decade in 47.6 vs 20.0%, p < 0.05). Symptoms most frequently associated with Group 1 patients included small volume and hard feces (85.0%, p < 0.01), excessive strain at stool (81.0%, p < 0.05), tenesmus and fecaloma formation (57.1 and 42.9%, p < 0.05); symptoms most frequently associated with Group 2 patients included mucous discharge, rectal bleeding and pain (86.7%, p < 0.05), prolonged toilet time (73.3%, p < 0.05), fragmented evacuation with or without digitation (66.7%, p < 0.005). Voiding outflow obstruction was more frequent in Group 1 (19.0 vs 13.3%; p < 0.05), while non-bacterial prostatitis and sexual dysfunction prevailed in Group 2 (26.7 and 46.7%, p < 0.05). At MR defecography, two major categories of findings were detected: a dyskinetic pattern (Type 1), seen in all Group 1 patients, which was characterized by non-relaxing puborectalis muscle, sand-glass configuration of the anorectum, poor emptying rate, limited pelvic floor descent and final residue ≥ 2/3; and a prolapsing pattern (Type 2), seen in all Group 2 patients, which was characterized by rectal prolapse/intussusception, ballooning of the levator hiatus with impingement of the rectal floor and prostatic base, excessive pelvic floor descent and residue ≤ 1/2. Posterolateral outpouching defined as perineal hernia was present in 28.6% of patients in Group 1 and were absent in Group 2. The average levator plate angle on straining differed significantly in the two patterns (21.3° ± 4.1 in Group 1 vs 65.6° ± 8.1 in Group 2; p < 0.05). Responses to the phone interview were obtained from 31 patients (18 of Group 1 and 13 of Group 2, response rate, 86.1%). Patients of Group 1 were always treated without surgery (i.e., biofeedback, dietary regimen, laxatives and/or enemas) which resulted in symptomatic improvement in 12/18 cases (66.6%). Of the patients in Group 2, 2/13 (15.3) underwent surgical repair, consisting of stapled transanal rectal resection (STARR) which resulted in symptom recurrence after 6 months and laparoscopic ventral rectopexy which resulted in symptom improvement. The other 11 patients of Group 2 were treated without surgery with symptoms improvement in 3 (27.3%).

CONCLUSIONS

The appearance of various abnormalities at MR defecography in men with ODS shows 2 distinct patterns which may have potential relevance for treatment planning, whether conservative or surgical.

Chronic constipation in Rome IV era: The Indian perspective

Chronic constipation (CC) is a common problem in the community and in gastroenterology practice all over the world including India. After release of Rome IV guidelines in April 2016, there is increasing interest among gastroenterologists and physicians in India to look into special issues on CC in the Indian perspective. There are important differences in the bowel habit, definition, epidemiology, and pathophysiology including dietary factors and management of CC in India as compared to the West. As severity and frequency of abdominal pain, a symptom essential to diagnose constipation-predominant irritable bowel syndrome (IBS-C) rather than functional constipation (FC), is less common among Indian patients, FC is commoner than IBS-C in India. The pathophysiological mechanisms of CC may include slow colon transit, fecal evacuation disorder (FED), or a combination of these; though CC in a third to half of patients presenting to tertiary care facilities may result from these pathophysiological mechanisms, most patients presenting to primary care may have lifestyle and dietary issues. The current Rome IV algorithm dictates to explore the underlying physiological factors in the pathogenesis of functional gastrointestinal disorders including CC, which may translate to its personalized management. However, the availability of the methods to explore pathophysiological factors and manage CC caused by FED non-pharmacologically (using biofeedback) in India is limited. Though several pharmacological agents are available in India to manage CC, there are several unmet needs in its treatment. This review explores CC in India in relation to these issues, some of which are unique in the Indian perspective.

Frequency, spectrum, and factors associated with fecal evacuation disorders among patients with chronic constipation referred to a tertiary care center in northern India

BACKGROUND

Data on fecal evacuation disorder (FED) causing chronic constipation (CC) is scanty in India.

METHODS

Prospectively maintained data of 249 consecutive patients with CC (Rome III) referred for investigations were retrospectively analyzed.

RESULTS

Of 249 patients (43.7 ± 16.2 years, 174 males), 135/242 (55.8 %), 57/249 (22.9 %), and 83/136 (61.0 %) had abnormal balloon expulsion test (>200 g), anorectal manometry [>100 mmHg resting pressure (n = 4), >167 mmHg squeeze pressure (n = 46), and both (n = 7)], and defecography (anorectal angle not opening by >15° during defecation, perineal descent ≥4 cm, and/or rectocele), respectively. Though 181/249 (72.6 %) had one test abnormality, 86/249 (34 %) had FED (greater than or equal to two abnormalities), 44/65 (67.6 %) of whom had a defecation index ≤1.4. Rome III criteria for irritable bowel syndrome were equally fulfilled by patients with and without FED [74/83 (89 %) vs. 117/144 (81.2 %); p = ns]. On univariate analysis, straining duration, prolonged straining [≥30 min; 21/39 (53.8 %) vs. 15/65 (23.1 %); p = 0.002], incomplete evacuation [75/77 (97.4 %) vs. 95/114 (83.3 %); p = 0.004], and >3 stools/week [60/75 (80 %) vs. 76/128 (60 %); p = 0.004] were commoner among the FED patients though age, gender, symptom duration, mucus, manual evacuation, and stool forms were comparable. Resting and squeeze pressures and balloon volume at maximum tolerable limit were higher, and the sphincter tended to be shorter in FED. Prolonged straining, incomplete evacuation, and squeeze pressure were significant on multivariate analysis. Manometry and defecography abnormalities were commoner among the female FED patients.

CONCLUSION

FED is not uncommon, which fulfills the Rome III criteria for IBS, and prolonged straining may be suggestive; abnormal defecography and manometry are commoner in female.

Two Etiological Reasons of Constipation: Anterior Rectocele and Internal Mucosal Intussusception

Chronic constipation is a common problem in the general population. Rome III criteria can be used for the diagnosis of chronic constipation. The aim of this study is to emphasize the importance of anterior rectocele and mucosal intussusception as two etiological factors for chronic constipation. One hundred patients were included in this study after excluding other causes of the constipation by medical history, physical examination, and laboratory and radiological studies in 108 total patients who were admitted consecutively to the outpatient clinic of the general surgery department of Dr. Sadi Konuk Bakirkoy Education and Research Hospital with the complaint of constipation between June 2009 and January 2010. It was found that 75 % of these patients had anterior rectocele and 66 % of them had internal intussusception which cause chronic constsipation. Anterior rectocele and internal rectal mucosal intussusception must be kept in mind as two significant reasons for chronic functional constipation.

Laparoscopic ventral mesh rectopexy in male patients with internal or external rectal prolapse

AIM

Laparoscopic ventral mesh rectopexy (LVMR) has been used to treat rectal prolapse, obstructed defaecation (OD), faecal incontinence (FI) and multicompartment pelvic floor dysfunction. Its value in treating men has been questioned. The aim of the present study was to assess the results in male patients.

METHOD

A password-protected electronic database of all LVMRs carried out in North Bristol NHS trust & Spire hospital between 2002 and 2013 was examined. In addition to the clinical outcome, quality of life (QoL), Cleveland Clinic Incontinence Score (CCIS), obstructed defecation syndrome (ODS) score, visual analogue score (VAS) for the severity of bowel and urinary symptoms and the numerical rating scale (NRS) for pain and patient-reported outcome measures were evaluated.

RESULTS

Sixty-eight men of median age 35 years and body mass index 26 kg/m(2) underwent LVMR for external rectal prolapse (18) or Grade III-V rectal intussusception (50) presenting with OD, FI and pelvic pain. Ten per cent had been labelled 'chronic idiopathic pelvic pain' and 60% had undergone previous haemorrhoidal surgery. Complications were minor and included urinary retention (10%). Eighty per cent of patients had an uncomplicated recovery with 24% being treated as day cases. There were no cases of impotence or retrograde ejaculation. Median follow-up was 42 (IQR 26-61) months. CCIS score improved from 4 (IQR 0-8) to 0 (IQR 0-0) (P < 0.001) and the ODS score from 18.5 (IQR 16-22) to 6 (IQR 5-8) (P < 0.001). Patients reported significant improvement in the NRS for pain and QoL (BBSQ-22) at 3 months (P = 0.000). The QoL and the VAS for bowel symptoms were maintained at 4 years. At the last follow-up 56 (82%) patients were asymptomatic and 6 (8.8%) had persisting symptoms. There was no case of recurrent external rectal prolapse.

CONCLUSION

LVMR is an effective treatment for external and symptomatic internal rectal prolapse in men, leading to significant improvement in QoL and function.

Conventional videodefecography: Pathologic findings according to gender and age

OBJECTIVES

To review the most common disorders depicted with conventional videodefecography, and to compare the defecographic abnormalities between symptomatic patients according to their gender and age.

METHODS

Conventional videodefecography studies of 300 patients (24 men, 266 women; mean age - 57.7) performed in a 32-month period were reviewed for the following parameters: anorectal angle, movement of the pelvic floor, intussusceptions, incontinence and rectocele. The results were analyzed using the chi-square test.

RESULTS

Normal findings were observed in 16.7% men and 7.5% women. In women, the most frequent pathological findings were rectocele (62%), descending perineum syndrome (42.8%), intussusceptions (33.8%), incontinence (10.5%), dyskinetic puborectalis syndrome (9.4%) and rectal prolapse (4.5%); in men the most frequent pathology was the dyskinetic puborectalis syndrome (37.5%). This syndrome is more likely in men than in women (p = 0.01; OR 5.78); descending perineum syndrome (p = 0.027; OR 2.8) is more likely to occur in women. Women with perineal descent younger than 50 years frequently present an increased descent during evacuation (81.8%), while those older than 50 years already have a low pelvic floor during rest (60.3%) (p < 0.001; OR 6.8), with little change in evacuation.

CONCLUSION

Videodefecographic findings vary with age and gender.

Early recognition of pelvic floor dyssynergia and colorectal assessment in Parkinson's disease associated with bowel dysfunction

AIM

Slow colonic transit time (CTT) and pelvic floor dyssynergia (PFD) are major contributors to constipation in patients with Parkinson's disease (PD). However, no symptom survey yet exists that effectively differentiates the contributing aetiologies. The significance of individual pelvic floor musculature behaviours and their relationship with colorectal dysmotility in constipated patients with PD are still controversial and need further clarification. We aimed to investigate how differentiated constipation-related symptoms of PD patients with constipation may identify constipation groupings and to register the pathophysiological features of the pelvic musculature.

METHOD

Our subjects undertook CTT, defaecography and the Knowles-Eccersley-Scott Symptom questionnaire. The pathological aetiologies were categorized as group 1 (slow CTT) and/or group 2 (puborectalis syndrome) and/or group 3 (pubococcygeus syndrome), in accordance with the CTT and defaecography results.

RESULTS

Constipation-related symptoms such as incomplete evacuation and defaecation difficulty yielded high post-test probabilities (81% and 88%, respectively) in groups 3 and 2, but a low post-test probability in group 1 (58%). Changes in the anorectal angle and perineum descent during straining were significantly correlated with CTT (r = 0.57 and r = 0.61, respectively) and with each other (r = 0.82).

CONCLUSION

Our findings that neural control of the puborectalis and pubococcygeus, along with colorectal peristalsis, were in a similar state of degeneration is key information that should assist physicians to instigate more effective management for colonic dysmotility or PFD.

Dynamic transperineal ultrasound in the workup of men with obstructed defecation: a pilot study

BACKGROUND

Dynamic transperineal ultrasound has been used in women for the noninvasive investigation of functional disorders of the posterior pelvic floor, but its use in men has been limited by technical difficulties related to the consistency of the male perineum.

OBJECTIVES

The aim of this study was to explore the efficacy of dynamic transperineal ultrasound in diagnosing posterior pelvic floor dysfunction in men.

DESIGN

This is a study of diagnostic accuracy.

SETTINGS

This study was performed at a public hospital.

PATIENTS

Forty-six men with symptoms of obstructed defecation were included.

INTERVENTIONS

All patients underwent dynamic transperineal ultrasound 1 week after standard defecography with manometric confirmation when rectoanal dyssynergy was observed.

MAIN OUTCOME MEASURES

Images were obtained, and anorectal angles were measured under resting conditions and during maximal strain. The accuracy of the sonographic method in diagnosing pelvic floor alterations was assessed against defecography (reference method).

RESULTS

: Anorectal angles measured with ultrasound and defecography were not significantly different under resting conditions or maximum strain. Sonographic and reference method findings were concordant in 41 (89.1%) of the cases (25 with rectoanal intussusceptions, 7 with rectorectal intussusceptions, 8 with rectoanal dyssynergy, and 1 with rectorectal intussusception and dyssynergy). In 1 patient with rectoanal intussusception, dynamic transperineal ultrasound was nondiagnostic (low image quality probably due to dehydration of perineal tissues). Discordant dynamic transperineal ultrasound findings included normal findings in another patient with rectoanal intussusception, diagnosis of rectoanal intussusception in 2 men with rectorectal intussusception, and failure to detect dyssynergy in a second patient with rectorectal intussusception and dyssynergy. The sensitivity, specificity, and Cohen κ indices for dynamic transperineal ultrasound were 92.6%, 90.5%, and 82% (rectoanal intussusception); 81.8%, 100%, and 87% (rectorectal intussusception); 90%, 100%, and 93% (rectoanal dyssynergy).

LIMITATIONS

This study was limited by its small size and by the absence of patients with other morphofunctional disorders associated with obstructed defecation.

CONCLUSIONS

Dynamic transperineal ultrasound is potentially useful for diagnosis and follow-up of posterior pelvic floor dysfunction in men.

Pathophysiological approach to bowel dysfunction after segmental colorectal resection for deep endometriosis infiltrating the rectum: a preliminary study

BACKGROUND

Colorectal segmental resection is performed worldwide in a majority of women presenting with symptomatic deep endometriosis infiltrating the rectum. The aim of the present study was to investigate the pathophysiological mechanisms involved in post-operative digestive dysfunction.

METHODS

We selected patients managed by colorectal resection for rectal endometriosis, who had developed post-operative severe constipation and whose follow up was superior to 24 months. To assess the mechanisms involved in the pathogenesis of this complaint, we performed a step-by-step work up including: low digestive tract endoscopy, colonic transit time measurement and when appropriate anorectal manometry, electromyography and defecographic evaluation.

RESULTS

Five out of 25 (20%) patients, whose age ranged from 27 to 41 years, were investigated for severe post-operative terminal constipation. Four different mechanisms responsible for terminal constipation were identified: tight stenosis of the colorectal anastomosis, post-operative neurological sequelae, colonic intussusception through the colorectal anastomosis and transit constipation that developed post surgery.

CONCLUSIONS

Post-operative constipation is a frequent complaint in women managed by colorectal resection for rectal endometriosis. A multidisciplinary approach is mandatory as pathophysiologic mechanisms may vary and prove difficult to understand. The risk of post-operative bowel dysfunction following colorectal endometriosis must be taken into account whenever this technique is proposed in young women presenting with a benign disease such as deep endometriosis.

Rectocele in children: a case report

Rectocele is an abnormal protrusion of the anterior wall of the rectum into the vagina. When symptomatic, it will typically cause obstructed defecation. It is almost exclusively found in females with rare reports in males and never been described in the literature in children younger than 18 years of age so far. We are presenting 3 cases of rectocele with obstructed defecation in the pediatric population. These children presented with the complaints of constipation along with refractory straining. They were diagnosed by defecography. Two were treated surgically and one conservatively. Surgical intervention completely cured the problem with uneventful postoperative course. Further multicenter studies with the aid of radiologic studies on children with "hard to treat" constipation should be considered to better define that disorder in the pediatric age group. A more vigilant approach may have implications in the prevention of more severe rectal and uterovaginal prolapse in the future.