The influence of defaecating proctograms on clinical decision-making in pelvic floor disorders

AIM

Defaecating proctogram (DP) studies have become an integral part of the evaluation of patients with pelvic floor disorders. However, their impact on treatment decision-making remains unclear. The aim of this study was to assess the concordance of decision-making by colorectal surgeons and the role of the DP in this process.

METHOD

Four colorectal surgeons were presented with online surveys containing the complete history, examination and investigations of 106 de-identified pelvic floor patients who had received one of three treatment options: physiotherapy only, anterior Delorme's procedure or anterior mesh rectopexy. The survey assessed the management decisions made by each of the surgeons for the three treatments both before and after the addition of the DP to the diagnostic work-up.

RESULTS

After the addition of the DP results; treatment choice changed in 219 (52%) of 424 surgical decisions and interrater agreement improved significantly from κ = 0.26 to κ = 0.39. Three of the four surgeons reported a significant increase in confidence. Agreement with the actual treatments patients received increased from κ = 0.21 to κ = 0.28. Intra-anal rectal prolapse on DP was a significant predictor of a decision to perform anterior mesh rectopexy.

CONCLUSION

The DP improves interclinician agreement in the management of pelvic floor disorders and enhances the confidence in treatment decisions. Intra-anal rectal prolapse was the most influential DP parameter in treatment decision-making.

Value of Defecography in the Diagnostic and Therapeutic Management of the Modified Wells Procedure for Rectal Prolapse

The main aim of this study was to explore the role of defecography in the preoperative diagnosis and postoperative evaluation of rectal prolapse surgery (modified Wells procedure). We collected and summarized the X-ray performance and then analyzed the results of 107 patients with defecatory dysfunction who underwent defecography from January 2020 to March 2021. Furthermore, the preoperative and 6-month postoperative defecography results and clinical symptoms of 25 patients who underwent rectal prolapse surgery (modified Wells procedure) were compared. Results showed that among the 107 patients with defecation dysfunction, women had worse defecography results than men (P < 0.01). A total of 25 patients successfully completed the surgery without complications such as infection and intestinal fistula and there was no recurrence at 12 months of follow-up. Compared with the preoperative results, anorectal angle during defecation, the depth of rectocele, and perineal descent were significantly improved after the surgery (P < 0.01). Moreover, the patient's feeling of obstructed defecation and incomplete defecation was significantly relieved compared to that before the procedure (P < 0.01). In conclusion, defecography can be used to diagnose rectal prolapse preoperatively and evaluate the surgical effect combined with clinical symptoms postoperatively, which provides a clinical reference.

Natural Orifice Endosonographic Colposuspension With Rectopexy for Combined Pelvic Organ Prolapse: A Feasibility Study

BACKGROUND

We describe a natural orifice technique for simultaneous endoluminal lateral suspension of apical vaginal wall and rectal prolapse fixation with ultrasound and fluoroscopic assistance.

IMPACT OF INNOVATION

The technique is minimally invasive, can be performed under regional anaesthesia, and avoids laparotomy or use of a mesh in addition to preserving the uterus.

TECHNOLOGY MATERIALS AND METHODS

This technique involves suprapubic transvaginal ventral suture colposuspension, fixation of the anterior rectal wall to the undersurface of the anterior abdominal wall and tack fixation of the posterior rectal wall to the underlying sacral promontory through a submucosal tunnel performed endoscopically with fluoroscopic and ultrasound assistance.

PRELIMINARY RESULTS

Seven patients with a mean age of 63 years were followed between 3 to 11 months.

CONCLUSIONS

This is a novel minimally invasive transluminal procedure that repairs concomitant rectal and vaginal prolapse in the same sitting.

FUTURE DIRECTIONS

Improvement in the instrument design and incorporation of endoluminal robotic systems will enhance the technical ease. The study needs validation in larger series of patients with longer follow-up.

Rectal mucosal prolapse with an emphasis on endoscopic ultrasound appearance

AIM

The diagnosis of mucosal prolapse syndrome (MPS) continues to be a challenge. Endoscopic ultrasound (EUS) is of clinical value in anorectal diseases. This study seeks to investigate the use of EUS in the diagnosis of MPS.

METHODS

A total of 39 patients diagnosed with MPS between June 2015 to December 2019 were included in this study. Their clinical histories, endoscopic images, EUS images, and pathological data were retrospectively collected, and the EUS images were reviewed to summarize the characteristics of MPS.

RESULTS

In total, 39 MPS patients were enrolled. The main presenting symptoms were bleeding (61.5%) and constipation (53.8%). Gross appearance of the rectal lesions was mainly classified into three types: 51.3% of the lesions were polypoidal/nodular, 33.3% were ulcerative and 15.4% were flat with erythematous mucosa only. A total of 10 patients underwent EUS operation. With regard to the EUS appearance of MPS, four patients with polypoidal/nodular lesions showed thickening of the mucosa on EUS. The diffuse thickening of the mucosa-submucosa layer and disappearance of the architectural structure was observed in four patients with ulcerative lesions. Finally, the thickening of the muscularis propria was observed in two flat lesions. The serosal layers were intact in all the MPS patients. Neither blood flow signals nor regional lymph nodes were observed on EUS.

CONCLUSION

The EUS characteristics for MPS corresponding to different gross appearance can be classified into three types. These findings suggest that EUS is useful in the diagnosis of MPS.

Radiological Changes After Resection Rectopexy in Patients with Rectal Prolapse-Influence on Clinical Symptoms and Quality of Life

BACKGROUND

Resection rectopexy is performed to correct the anatomic defect associated with rectal prolapse. The aim of the study was to determine whether the change in the radiological prolapse grade has an influence on patients' symptoms and quality of life.

METHODS

The study investigated 40 patients who underwent resection rectopexy for rectal prolapse. The following were determined before and after surgery: radiological prolapse grade, anorectal angle and pelvic floor position in defecography, clinical symptoms (Cleveland Clinic Incontinence and Constipation Scores, Kelly-Hohlschneider Score), quality of life.

RESULTS

Defecography revealed postoperative improvement in the prolapse grade and pelvic floor position (p < 0.05). The clinical symptoms and quality of life improved in both, the total population (n = 40) and in patients with improved radiological prolapse grade (n = 30): all clinical scores (p < 0.05), SF-36 (vitality, social role, mental health p < 0.05), and Fecal Incontinence Quality of Life Scale (lifestyle, coping, embarrassment p < 0.05). Patients without improved radiological findings showed no change in their symptoms or quality of life.

CONCLUSION

Our study demonstrates that the radiological prolapse grade is improved by resection rectopexy. Correction of the anatomic defect was associated with improvement in symptoms and quality of life. Defecography may therefore be useful in the postoperative assessment of persistent symptoms or reduced quality of life.

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.

New-onset rectoanal intussusception may not result in symptomatic improvement after laparoscopic ventral rectopexy for external rectal prolapse

BACKGROUND

This study was designed to assess defecatory function in patients who underwent laparoscopic ventral rectopexy (LVR) for external rectal prolapse (ERP).

METHODS

Thirty-one patients who underwent evacuation proctography 6 months postoperatively were assessed. Preoperative proctography had been performed in 21 patients of these patients. Defecatory function was evaluated using the constipation scoring system (CSS) and fecal incontinence severity index (FISI).

RESULTS

The findings of postoperative proctography revealed no full-thickness ERP in any patient, although in 10 patients the ERP was replaced by rectoanal intussusception (RAI). Of the 31 patients, 30 presented with fecal incontinence preoperatively. Ten of 30 had new-onset RAI. Six months postoperatively, a reduction of at least 50 % in the FISI score of the patients with new-onset RAI tended to be significantly smaller than in the patients without RAI (6/10 vs. 18/20, p = 0.141). Seventeen patients presented with obstructed defecation preoperatively. Seven of them had new-onset RAI. Six months postoperatively, a reduction of at least 50 % in their CSS score in the patients with new-onset RAI was significantly smaller than in patients without RAI (0/7 vs. 8/10, p = 0.002).

CONCLUSIONS

Evacuation proctography showed new-onset RAI in some patients with ERP who underwent LVR, which was associated with a lack of symptomatic improvement.

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.

Colpocystodefecography in obstructed defecation: is it really useful to the surgeon? Correlating clinical and radiological findings in surgery for obstructed defecation

OBJECTIVE

Colpocystodefecography images the pelvic floor with the dynamics of defecation, but various authors claim that it overestimates clinical findings. The aim of this study was to evaluate the pre- and postoperative consistency between clinical and colpocystodefecographic findings in patients undergoing surgery for obstructed defecation. METHOD Between June 2001 and September 2003, 20 patients underwent transvaginal posterior colpoperineorrhaphy and rectal mucosal prolapsectomy with one circular stapler for symptomatic rectocele and concomitant anorectal prolapse. They were prospectively evaluated both before surgery by designed questionnaire on constipation and incontinence, proctological, gynaecological and urological examinations, colpocystodefecography and anorectal manometry, and after operation at 6 months by questionnaire and a proctological check-up. The mean follow-up was 30 months (24-48 months).

RESULTS

At 6 months the questionnaire revealed a major response in terms of symptoms. The proctological visit confirmed the absence of rectocele in 19 (95%) patients, while the anorectal prolapse had completely disappeared in 17 (85%) patients. Postoperative colpocystodefecography demonstrated a general reduction in the dimensions of the rectocele, which had completely disappeared in five (25%) patients; 40% of the patients had a persistent anorectal prolapse.

CONCLUSION

Preoperative data analysis showed a statistically significant correlation between clinical and radiological findings. Postoperatively the global clinical assessment correlated well with patient satisfaction, while there was evidence of a statistically significant difference between the radiological and clinical findings. Routine postoperative use of colpocystodefecography is unjustified unless there is clinical evidence of surgical failure.

Ultrasonographic patterns in patients with obstructed defaecation

BACKGROUND

Anal ultrasound is helpful in assessing organic anorectal lesions, but its role in functional disease is still questionable. The purpose of the present study is to assess anal-vaginal-dynamic perineal ultrasonographic findings in patients with obstructed defecation (OD) and healthy controls.

MATERIALS AND METHODS

Ninety-two consecutive patients (77 women; mean age 51 years; range 21-71) with symptoms of OD were retrospectively evaluated. All patients underwent digital exploration, endoanal and endovaginal ultrasound (US) with rotating probe. Forty-one patients underwent dynamic perineal US with linear probe. Anal manometry and defaecography were performed in 73 and 43 patients, respectively. Ultrasonographic findings of 92 patients with symptoms of OD were compared to 22 healthy controls. Anismus was defined on US when the difference in millimetres between the distance of the inner edge of the puborectalis muscle posteriorly and the probe at rest and on straining was less then 5 mm. Sensitivity and specificity were calculated by assuming defaecography as the gold standard for intussusception and rectocele and proctoscopy for rectal internal mucosal prolapse. Since no gold standard for the diagnosis of anismus was available in the literature, the agreement between anal US and all other diagnostic procedures was evaluated.

RESULTS

The incidence of anismus resulted significantly higher (P < 0.05) in OD patients than healthy controls on anal (48 vs 22%), vaginal (44 vs 21%), and dynamic perineal US (53 vs 22%). A significantly higher incidence of rectal internal mucosal prolapse was observed in OD patients when compared to healthy controls on both anal (61.9 vs 13.6%, P < 0.0001) and dynamic perineal US (51.2 vs.9% P = 0.001). For the diagnosis of rectal internal mucosal prolapse, anal US had a 100% sensitivity and specificity. For diagnosis of rectal intussusception, anal US had an 83.3% sensitivity and 100% specificity and perineal US had a 66.6% sensitivity and 100% specificity. In the diagnosis of anismus, anal ultrasonography resulted in agreement with perineal and vaginal US, manometry, defaecography, and digital exam (P < 0.05). Other lesions detected by US in patients with OD include solitary rectal ulcer, rectocele and enterocele. Damage of internal and/or external sphincter was diagnosed at anal US in 19/92 (20%) patients, all continent and with normal manometric values.

CONCLUSION

Anal, vaginal and dynamic perineal ultrasonography can diagnose or confirm many of the abnormalities seen in patients with OD. The value of the information obtained by this non-invasive test and its role in the diagnostic algorithm of OD is yet to be defined.

Ultrasound assessment of pelvic organ prolapse: the relationship between prolapse severity and symptoms

OBJECTIVE

At present little information is available to help define whether a certain degree of pelvic organ prolapse is clinically relevant. We performed a retrospective study to define cut-offs for significant pelvic organ descent on the basis of prolapse symptoms.

METHODS

At a tertiary urogynecological center, 735 women with symptoms of lower urinary tract dysfunction and prolapse were seen for interview, clinical examination, multi-channel urodynamics and ultrasound imaging, while supine and after voiding, for prolapse quantification. Women with multi-compartment prolapse, i.e. those in whom no compartment was clearly dominant were excluded. Receiver-operator statistics were used to test pelvic organ descent as a predictor of prolapse symptoms.

RESULTS

Mean age was 55.1 years, mean parity 2.8 (range, 0-12). Symptoms of prolapse were reported by 188 women (25.6%). Seventy-four showed a symptomatic multi-compartment prolapse and were excluded, 56 symptomatic women had cystoceles and 48 had rectoceles. Symptomatic cystoceles descended on average to 23.8 mm below the symphysis pubis and symptomatic rectoceles to 21.4 mm below the symphysis pubis. Descent was strongly associated with symptoms of prolapse (both, P < 0.001). Receiver-operating characteristics (ROC) statistics suggested a cut-off of 10 mm below the symphysis pubis for cystocele, and 15 mm below the symphysis pubis for rectocele. ROC curves were similar for both compartments (area under the curve, 0.857 and 0.821, respectively).

CONCLUSIONS

Descent of the bladder to > or = 10 mm and of the rectum to > or = 15 mm below the symphysis pubis are strongly associated with symptoms, and these values are proposed as cut-offs for the diagnosis of significant prolapse on the basis of ROC statistics.

Dynamic pelvic three-dimensional computed tomography for investigation of pelvic abnormalities in patients with rectocele and rectal prolapse

BACKGROUND

Dynamic three-dimensional computed tomography (D-3DCT: high-speed helical scanning during defecation) was used for morphological evaluation of intrapelvic structures in patients with rectal prolapse and rectocele.

METHODS

Twenty-five patients with rectal prolapse or rectocele diagnosed by conventional defecography (CD) or clinical findings were additionally investigated with D-3DCT. D-3DCT images were acquired using a multislice CT system with a 16-row detector during simulated defecation. Helical scanning was performed with a slice thickness of 1 mm, a helical pitch of 15 s/rotation, and a table movement speed of 35 mm/s. The contrast medium, 100 ml of iopamidol (370 mg/ml), was injected at a rate of 2.5 ml/s to enhance contrast with other structures, and scan start was triggered by using a function for automatically determining the optimal scan timing.

RESULTS

Among the eight patients with rectocele, additional intrapelvic disorders were diagnosed in five (enterocele, 4; cystocele, 1; and uterine prolapse, 1) with D-3DCT. In the 17 patients with rectal prolapse, concomitant intrapelvic disorders were found in six (intussusception, 3; cystocele, 2; uterine prolapse, 2; rectocele, 1; and vaginal prolapse, 1).

CONCLUSIONS

D-3DCT can be a useful diagnostic tool for investigation of pelvic pathology in patients with rectocele and rectal prolapse.

PET-CT-Untersuchungen der Halterung und Kontinenz der Beckenorgane

Like all other organs in the chest or abdominal cavities, pelvic organs are not suspended by specialized ligaments such as those in the skeletomuscular system. In spite of this, the organs of the pelvis remain well suspended within their cavity even during evacuation. This support system for these organs consists of inconspicuous smooth muscle elements scattered throughout pelvic structural fat tissue and fascial structures, in particular Denonvilliers' fascia. We used PET-CT studies to identify spontaneous muscle activity in the pelvis, which is strongest at Denonvilliers' fascia. We were able to correlate continence function, filling, and evacuation of pelvic organs with this spontaneous muscle activity that leads to stiffening and relaxation of the muscular walls of these organs. During the course of different disease processes such as visceral prolapse, these pelvic support structures are prone to fail gradually. Surgical interventions should take the pelvic support system into account to avoid therapeutic errors.

Posterior compartment prolapse on two-dimensional and three-dimensional pelvic floor ultrasound: the distinction between true rectocele, perineal hypermobility and enterocele

OBJECTIVES

Posterior compartment descent may encompass perineal hypermobility, isolated enterocele or a 'true' rectocele due to a rectovaginal septal defect. Our objective was to determine the prevalence of these conditions in a urogynecological population.

METHODS

One hundred and ninety-eight women were clinically evaluated for prolapse and examined by translabial ultrasound, supine and after voiding, using three-dimensional capable equipment with a 7-4-MHz volume transducer. Downwards displacement of rectocele or rectal ampulla was used to quantify posterior compartment prolapse. A rectovaginal septal defect was seen as a sharp discontinuity in the ventral anorectal muscularis.

RESULTS

Clinically, a rectocele was diagnosed in 112 (56%) cases. Rectovaginal septal defects were observed sonographically in 78 (39%) women. There was a highly significant relationship between ultrasound and clinical grading (P < 0.001). Of 112 clinical rectoceles, 63 (56%) cases showed a fascial defect, eight (7%) showed perineal hypermobility without fascial defect, and in three (3%) cases there was an isolated enterocele. In 38 (34%) cases, no sonographic abnormality was detected. Neither position of the ampulla nor presence, width or depth of defects correlated with vaginal parity. In contrast, age showed a weak association with rectal descent (r = -0.212, P = 0.003), the presence of fascial defects (P = 0.002) and their depth (P = 0.02).

CONCLUSIONS

Rectovaginal septal defects are readily identified on translabial ultrasound as a herniation of rectal wall and contents into the vagina. Approximately one-third of clinical rectoceles do not show a sonographic defect, and the presence of a defect is associated with age, not parity.

Influence of rectal prolapse on the asymmetry of the anal sphincter in patients with anal incontinence

BACKGROUND

Anal sphincter defects have been shown to increase pressure asymmetry within the anal canal in patients with fecal incontinence. However, this correlation is far from perfect, and other factors may play a role. The goal of this study was to assess the impact of rectal prolapse on anal pressure asymmetry in patients with anal incontinence.

METHODS

44 patients, (42 women, mean age: 64 (11) years), complaining of anal incontinence, underwent anal vector manometry, endo-anal ultrasonography (to assess sphincter defects) and pelvic viscerogram (for the diagnosis of rectal prolapse). Resting and squeeze anal pressures, and anal asymmetry index at rest and during voluntary squeeze were determined by vector manometry.

RESULTS

Ultrasonography identified 19 anal sphincter defects; there were 9 cases of overt rectal prolapse, and 14 other cases revealed by pelvic viscerogram (recto-anal intussuception). Patients with rectal prolapse had a significantly higher anal sphincter asymmetry index at rest, whether patients with anal sphincter defects were included in the analysis or not (30 (3) % versus 20 (2) %, p < 0.005). Among patients without rectal prolapse, a higher anal sphincter asymmetry index during squeezing was found in patients with anal sphincter defects (27 (2) % versus 19 (2) %, p < 0.03).

CONCLUSIONS

In anal incontinent patients, anal asymmetry index may be increased in case of anal sphincter defect and/or rectal prolapse. In the absence of anal sphincter defect at ultrasonogaphy, an increased anal asymmetry index at rest may point to the presence of a rectal prolapse.

Dynamic evaluation of the anorectum

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

Dynamic evaluation of female pelvic organ prolapse by extended proctography

More accurate preoperative assessment by DCP or MR imaging hopefully should reduce the incidence of operative failure. These techniques help the surgeon to plan the different components of pelvic reconstructive surgery and, importantly, whether a transvaginal or transabdominal approach will be required. The current trend is toward the transabdominal route. Available evidence suggests that the reoperative rate is halved when the abdominal approach is employed. Large enteroceles and marked vaginal vault prolapse, in particular, are much more amenable to correction by transabdominal surgery. It should be recognized that enteroceles and sigmoidoceles often escape preoperative detection unless radiologic evaluation is performed. Global assessment of pelvic organ prolapse is optimized by ensuring that competing organs are effectively emptied by virtue of a triphasic approach. As expressed succinctly by Halligan, "the global pelvic floor specialist has arrived, and his closest ally is the radiologist".

Incidence of occult rectal prolapse in patients with clinical rectoceles and defecatory dysfunction

OBJECTIVE

The purpose of this study was to determine the incidence of occult rectal prolapse (rectal intussusception) by defecating proctography in patients with clinical rectoceles and defecatory dysfunction.

STUDY DESIGN

Patients who were seen from September 2000 through August 2001 with defecatory dysfunction and clinical rectoceles underwent single contrast defecating proctography. Radiologists who specialized in gastrointestinal fluoroscopy interpreted the results, which were retrieved from a computerized database. Study Design: Sixty patients who met the inclusion criteria were evaluated. Twenty patients (33%) had intussusception; 58 patients (97%) had rectocele; 1 patient (1.7%) had sigmoidocele, and 6 patients (10%) had anismus (paradoxic contraction of the puborectalis).

RESULTS

All but 1 case of intussusception was associated with a rectocele radiographically. Anismus was associated with rectoceles radiographically, except in 1 patient for whom it was the sole finding.

CONCLUSION

The data suggest a 33% incidence of occult rectal prolapse in patients with clinical rectoceles and defecatory dysfunction. This is highly clinically significant because one third of patients who are examined for defecatory dysfunction and rectocele may require sigmoid resection rectopexy along with other reconstructive procedures to restore pelvic floor function and prevent symptomatic recurrence.

[Evaluation of Longo's technique for haemorrhoidectomy by doppler ultrasound measurement of the superior rectal artery]

Stapler-haemorrhoidectomy causes theoretically a durable reposition of the prolapsed haemorrhoidal cushions and a reduction of the arterial inflow by clipping mucosa and submucosa. Until now, however, no exact data exist with respect to a potential reduction of the arterial inflow.

METHODS

The question of a sufficient interruption of the end branches of the superior rectal artery should be answered with doppler ultrasound measurements before and after stapler-haemorrhoidectomy.

RESULTS

The measurements were performed on 45 patients before and one month after stapler-haemorrhoidectomy. Preoperatively in all patients the three main branches of the artery at three, seven and eleven o'clock could be detected by doppler ultrasound. In 67 % of the patients a fourth, in 16 % a fifth and in 13 % a sixth vessel could be located. One month postoperatively in 80 % of the patients all main branches were further seen. In 16 % of the cases two main vessels, in 4 % only one main vessel could be identified. There was no correlation between postoperative outcome and number of vessels detected postoperatively.

CONCLUSION

It is concluded that the postoperative outcome after stapler-haemorrhoidectomy does not depend on the complete interruption of the arterial inflow of the haemorrhoids. The complete reposition of the haemorrhoidal prolapse and thereby the improvement of the venous reflux out of the haemorrhoidal cushions might be more important.

Dynamic imaging of pelvic floor with transperineal sonography

Real-time transperineal sonography has enhanced the appreciation of morphology and dynamics of the pelvic floor. Standard images are obtained from longitudinal and axial planes by placing the transducer between the vagina and rectum. This fast, effective, noninvasive and inexpensive examination represents the preferred initial diagnostic imaging tool for women with pelvic floor dysfunctions, such as prolapse and incontinence.

Rectal prolapse in women with other defects of pelvic floor support

OBJECTIVES

We describe a series of patients with rectal prolapse who had other pelvic floor defects.

STUDY DESIGN

Patients with rectal prolapse that we examined between 1990 and 2000 were reviewed.

RESULTS

During this time frame 55 patients with rectal prolapse were seen by one of us. Fifty-two of these patients had other defects of pelvic floor support and are the subject of this report. The diagnosis was established in all patients with video defecography. Thirty-nine of the patients had internal (occult) prolapse that simulated either a rectocele or an enterocele. The mean number of surgical procedures for pelvic floor support before the diagnosis of rectal prolapse was 1.5. Thirty-one patients underwent a sigmoid resection with rectopexy, 12 underwent a rectopexy alone, 3 underwent a Ripstein procedure, 2 elderly patients had physical therapy alone, and the other 4 patients had surgical correction of the rectal prolapse before being referred for repair of vaginal vault prolapse. Other procedures performed simultaneously included sacral colpopexy, sacrospinous suspension, rectopubic urethropexy, and abdominal fixation of the vagina to the uterosacral ligaments.

CONCLUSIONS

Rectal prolapse frequently coexists with other pelvic floor defects. Internal rectal prolapse may simulate a rectocele or enterocele and requires defecography to establish the diagnosis. Rectopexy (with or without sigmoid resection) is a satisfactory technique for correction and may be combined with other reconstructive procedures on the pelvic floor.

Defecographic measurements of rectal intussusception and prolapse in patients and in asymptomatic subjects

OBJECTIVE

The aim of this study was to provide measurements for the defecographic diagnosis of rectal intussusception and rectal prolapse.

MATERIALS AND METHODS

Four hundred thirty-seven consecutive patients with defecation and micturition disorders and gynecologic complaints were studied by means of defecography (120 patients), colpodefecography (17 patients), or cystocolpodefecography (300 patients). As a control group, 43 asymptomatic subjects underwent defecographic examination.

RESULTS

Thirty-five patients were found to have rectal intussusception and 18, to have rectal prolapse. Anterior and posterior rectal wall folding thickness, intussuscipiens diameter, intussusceptum lumen diameter, and the ratio between the intussuscipiens diameter and the intussusceptum lumen diameter were measured in all patients. The findings were compared with those obtained in 13 of 43 asymptomatic subjects with rectal outline changes mimicking intussusception. Rectal folding thickness and the ratio between the intussuscipiens diameter and the intussusceptum lumen diameter were significantly greater in subjects with rectal intussusception and rectal prolapse than in asymptomatic subjects with rectal mucosa folding.

CONCLUSION

Our findings suggest that dynamic evacuation radiology contributes to making a differential diagnosis between rectal intussusception and mucosal folds in the rectum.

[Use of modified irrigoradioscopy in the diagnosis of external and internal rectal prolapse]

The paper gives colonic X-ray findings in 39 patients with rectal prolapse. Of them, 20 and 19 patients were found to have internal and external rectal prolapse, respectively. Studies were conducted by the modified irrigoscopy developed by the State Coloproctology Research Center, Ministry of Health of the Russian Federation, to explore the anatomic and functional status of the rectum and the fundus of the pelvis in patients with impaired defecation. The X-ray sign of circular invagination that had been detected by the authors allowed them to make the diagnosis of internal rectal prolapse with the greatest assurance. The modified irrigoscopy in combination with oral enterography for external rectal prolapse could show associated changes, including enterocele and sigmocele.

[Radiologic investigation of external rectal prolapse. Assessment in 48 patients with defecography, seven of them also with dynamic CT of the pelvis]

PURPOSE

To report our personal experience in 48 patients with external rectal prolapse examined with defecography, evaluating radiological signs and the indications for surgical treatment. We also report the results of 7 patients with severe prolapse submitted to dynamic CT of pelvis.

MATERIAL AND METHODS

The findings relative to 48 patients suffering from external prolapse, 27 women and 21 men, (mean age 58 years), were retrospectively reviewed. In our study protocol the patient is made to sit on a defecographic commode with the pelvis in lateral projection and radiographic images are acquired at rest, on contraction and on evacuation. Dynamic CT of pelvis with axial and coronal scans of the pelvic floor was carried out in 7 patients with severe prolapses. Twenty-six of 48 patients underwent rectopexy.

RESULTS

The main symptoms were anorectal and perineal weight sensation (93%), perineal disturbance in the sitting position (91%) and anorectal pain extended to sacral area (83%). Manometry, which was performed in 36 cases, showed a rectoanal inhibitory reflex evokable at high volumes of air, especially in incontinent subjects. Defecography demonstrated external rectal prolapse in all cases; rectal intussusception in 32, mucosal prolapse in 30, abnormal widening of the anorectal angle in 24 (16 of them were incontinent), rectocele in 22 and perineal descent syndrome in 16 cases.

DISCUSSION AND CONCLUSIONS

External rectal prolapse is sometimes a dynamic progression of a rectal intussusception. In anorectal intussusceptions, the invaginatum involves the anal canal, thus causing the external prolapse. Defecography clearly shows the continuation of invagination out of the anus, with the formation of prolapse. Dynamic CT proved accurate in detecting the rectum morphology, but added no further information to defecography, except for the diastasis of anosphincterial muscles. Therefore, we conclude that defecography is the method of choice, though complementary to other instrumental techniques such as manometry, electromyography and endoscopy, in the diagnostic workup of these patients. Moreover, it can recognize other alterations, such as incontinence and rectocele, which can be submitted to surgical correction with rectopexy.

Evaluation of pelvic descent disorders by dynamic contrast roentgenography

PURPOSE

For precise diagnosis and rational treatment of the increasing number of patients with descent of intrapelvic organ(s) and anatomic plane(s), dynamic contrast roentgenography of multiple intrapelvic organs and planes is described.

METHODS

Sixty-six patients, consisting of 11 males, with a mean age (+/- standard deviation) of 65.6+/-14.2 years and with chief complaints of intrapelvic organ and perineal descent or defecation problems, were examined in this study. Dynamic contrast roentgenography was obtained by opacifying the ileum, urinary bladder, vagina, rectum, and the perineum. Films were taken at both squeeze and strain phases. On the films the lowest points of each organ and plane were plotted, and the distances from the standard line drawn at the upper surface of the sacrum were measured. The values were corrected to percentages according to the height of the sacrococcygeal bone of each patient. From these corrected values, organ or plane descents at strain and squeeze were diagnosed and graphically demonstrated as a descentgram in each patient.

RESULTS

Among 17 cases with subjective symptoms of bladder descent, 9 cases (52.9 percent) showed roentgenographic descent. By the same token, among the cases with subjective feeling of descent of the vagina, uterus, peritoneum, perineum, rectum, and anus, roentgenographic descent was confirmed in 15 of 20 (75 percent), 7 of 9 (77.8 percent), 6 of 16 (37.5 percent), 33 of 33 (100 percent), 25 of 37 (67.6 percent), and 22 of 36 (61.6 percent), respectively. The descentgrams were divided into three patterns: anorectal descent type, female genital descent type, and total organ descent type.

CONCLUSIONS

Dynamic contrast roentgenography and successive descentgraphy of multiple intrapelvic organs and planes are useful for objective diagnosis and rational treatment of patients with descent disorders of the intrapelvic organ(s) and plane(s).

Detection of a rectocele-like prolapse in the colonic J-pouch using pouchography: cause or effect of evacuation difficulties?

The functional outcome after a low anterior resection for rectal cancer is improved by a colonic J-pouch reconstruction. One functional problem with J-pouches is difficulty in evacuation, which is more common with large reconstructions. Since rectoceles are common findings on defecography in patients with evacuation difficulties, we proposed that a rectocele-like prolapse may be thus found in patients with large J-pouches. Pouchography was used to identify a rectocele-like prolapse (RP) in 26 patients with a 10-cm J-pouch (10-J group) and 27 patients with a 5-cm J-pouch (5-J group). Pouchography was performed at 3 months, 1 year, and 2 years after surgery. Functional assessments were performed 1 year postoperatively. Clinical function was evaluated using a questionnaire. The evacuation function was evaluated by the balloon expulsion and saline evacuation test. No patients had an RP at 3 months or 1 year after surgery. An RP was significantly more common in the 10-J group than in the 5-J group at 2 years after surgery (P = 0.0374). An evacuation difficulty was significantly more common in the 10-J group than in the 5-J group. The evacuation function in the 10-J group was also significantly inferior to that in the 5-J group. An RP appearing 2 years after surgery is more common in patients with evacuation difficulties and large colonic J-pouch reconstructions.

Female pelvic organ prolapse: a comparison of triphasic dynamic MR imaging and triphasic fluoroscopic cystocolpoproctography

OBJECTIVE

This study compared dynamic MR imaging with fluoroscopic cystocolpoproctography for the detection and measurement of prolapse of pelvic organs.

SUBJECTS AND METHODS

Ten patients underwent triphasic dynamic MR imaging and triphasic fluoroscopic cystocolpoproctography with identical amounts of contrast material to opacify the bladder, vagina, and rectum. The dynamic MR imaging procedure included cine-loop presentation. Each examination was analyzed to determine the presence and extent of prolapse of pelvic organs based on specific measurements.

RESULTS

Both dynamic MR imaging and fluoroscopic cystocolpoproctography revealed 10 rectoceles (mean extents, 2.85 and 2.45 cm, respectively). Nine cystoceles were revealed by both dynamic MR imaging (mean extent, 4.05 cm) and fluoroscopy (mean extent, 4.55 cm). Seven enteroceles were revealed, one of which was initially not seen on dynamic MR imaging. Two sigmoidoceles were revealed, one of which was not seen on fluoroscopy. The mean extent of the enteroceles and sigmoidoceles on dynamic MR imaging was 3.50 cm, and the mean extent on fluoroscopy was 4.25 cm. Nine of the 10 patients were able to defecate in the supine position on the MR imaging table. Patients were divided equally in their preference for dynamic MR imaging or fluoroscopic cystocolpoproctography.

CONCLUSION

Triphasic dynamic MR imaging and triphasic fluoroscopic cystocolpoproctograpy show similar detection rates for prolapse of pelvic organs. Although dynamic MR imaging underestimates the extent of cystoceles and enteroceles, it has the advantage of revealing all pelvic organs and the pelvic floor musculature in a multiplanar cine-loop presentation.

Resection rectopexy for rectal prolapse. The laparoscopic approach

BACKGROUND

Resection rectopexy through open laparotomy is an established procedure for the treatment of rectal prolapse.

METHODS

Resection rectopexy was successfully performed in 10 multiparous women by the laparoscopic approach (LAP), and the results were compared to those of eight women with laparotomy resection rectopexy (OPEN). Preoperative and postoperative assessment included anorectal manometry, defecography, and measurement of large-bowel transit.

RESULTS

The duration of the operation was longer in the LAP than in the OPEN group (p < 0.01). Morbidity was lower (p < 0.01) and hospital stay was shorter (p < 0.001) after the LAP than in the OPEN group. Prolapse was cured in all cases. Postoperatively, anal resting and squeeze pressures and rectal compliance increased significantly in both groups of patients (p = 0.007, p = 0.003, and p < 0.001, respectively). In all patients, the operation resulted in acceleration of large-bowel transit (p < 0.001) and in more obtuse anorectal angles at rest (p = 0.007). In addition, sampling events were observed more commonly (p = 0.008) postoperatively. Preoperatively, incontinence was present in 13 patients (seven LAP and six OPEN) and persisted in four of them after rectopexy (two LAP and two OPEN).

CONCLUSIONS

Resection rectopexy for rectal prolapse can be performed safely via the laparoscopic route. Recovery is uneventful and of shorter duration after the laparoscopic than after the open approach. Similarly satisfactory functional results are obtained with both procedures.

[Defecography in rectal wall prolapse conditions]

INTRODUCTION

Pelvic floor and rectal prolapse conditions have greatly benefitted by new imaging and instrumental diagnostic approaches, and especially defecography, for both pathophysiological interpretation and differential diagnosis. We investigated the efficacy of defecography in the assessment of rectal prolapse, and in particular the role of videoproctography in diagnosing such dynamic disorders.

MATERIAL AND METHODS

We selected 224 patients with rectal prolapse from a series of 1,190 consecutive subjects with evacuation disturbances examined in the last 5 years with defecography combined with videoproctography. The patients were 176 women and 48 men ranging in age 32-79 years (mean: 48). Defecography was carried out with Mahieu's technique, but we changed the filter position slightly. Sixty-seven per cent of our patients had been submitted to sigmoidoscopy, but this examination does not usually show rectal intussusception. Occult blood test in feces and double contrast barium enema were carried out in 42% and 38% of cases, respectively, to exclude any organic conditions of colon.

RESULTS

Mucosal prolapse was more frequent than intussusception (71% and 34%, respectively); rectal walls went out through the anus in 12 cases of anorectal intussusception and thus caused external rectal prolapse. Rectal prolapse was associated with other anorectal alterations, such as rectocele, perineal descent and puborectalis muscle syndrome, in 96 cases.

DISCUSSION AND CONCLUSIONS

The dynamic changes of ampulla are well depicted by videoproctography, which showed anorectum normalization and spontaneous reduction of invagination after intussusception. Defecography exhibited good capabilities in showing rectal wall function abnormalities. Finally, some features of videoproctography such as low radiation dose, noninvasiveness and ease of execution, make the examination acceptable to patients with anorectal disorders and for the follow-up of rectal prolapse.

Defecography: does parity play a role in the development of rectal prolapse?

Few studies related to parity address the changes in anorectal function in women. Since the majority of patients with rectal prolapse are women, we undertook this study to assess the role of parity in the development of rectal prolapse. We retrospectively reviewed defecography studies performed on 354 female patients over a 10-year period. Studies noting the presence of intra-anal and external rectal prolapse (full thickness protrusion of the rectum into and through the anal sphincter) were reviewed. Cases with intrarectal or hidden rectal prolapse, a condition of lesser clinical importance, were excluded. The obstetric histories of the patients with rectal prolapse (n = 27) were compared to those of patients without rectal prolapse (n = 88). There was a larger proportion of nulliparous women in the rectal prolapse group than in the group without rectal prolapse, suggesting that factors in addition to parity play a role in the development of rectal prolapse. However, parous women with rectal prolapse had delivered significantly more children (3.3) than parous women without prolapse (2.5) (P = 0.03). The exact cause of rectal prolapse remains unclear. Childbearing appears to play a limited role in its pathogenesis since nulliparous women are also at risk of developing rectal prolapse.

Pelvic floor descent: dynamic MR imaging using a half-Fourier RARE sequence

Dynamic magnetic resonance imaging (MRI) using a single shot fast spin-echo technique was evaluated as a noninvasive alternative to cystourethography or colpocystorectography in patients with pelvic organ prolapse and/or urinary incontinence. Thirty-two patients were included in this prospective study. Colpocystorectography was performed in 10 patients who previously had undergone hysterectomy and in 2 patients without history of hysterectomy with clinical suspicion of rectoceles. Bead-chain cystourethrography was performed in 20 patients without hysterectomy. For dynamic MRI, a single-slice half-Fourier RARE sequence (imaging time 2 seconds) was used to depict the pelvic organs at different levels of pelvic strain. The results obtained with dynamic MRI were correlated with the x-ray findings. All 17 cystoceles, 10 rectoceles, 2 enteroceles, and 7 vaginal prolapses could be demonstrated on MRI. Diagnostic information gained from these images was equivalent to that obtained with colpocystorectography and superior to that obtained with cystourethrography; with the latter, important findings were missed (four rectoceles). We conclude that dynamic MRI of the pelvic floor with a half-Fourier RARE sequence can reliably detect descents of all three pelvic compartments, that it requires no contrast agent, and that no radiation exposure is involved.

[The defecographic and clinical aspects of the solitary rectal ulcer syndrome]

INTRODUCTION

Solitary rectal ulcer syndrome is a complex evacuation disorder characterized by a benign ulcerative lesion of the distal rectum; the main symptom is rectal bleeding, but mucus discharge and difficult evacuation may be associated. The clinical, endoscopic and radiologic findings of solitary rectal ulcer syndrome are evaluated in this study. The role of defecography in the diagnosis of mucosal ulceration and morphofunctional alterations such as rectal prolapse and intussusception are investigated.

MATERIAL AND METHODS

In the last 5 years, 27 patients (19 women and 8 men; mean age: 38 years; range: 13-70 years) complaining of obstructed evacuation and rectal bleeding were examined with fibrosigmoidoscopy with biopsy, and defecography combined with videoproctography. Defecography was carried out sitting the patients on a defecographic chair with the pelvis in lateral projection. The images were acquired at rest, under straining, during squeezing and evacuation.

RESULTS

Endoscopy and biopsy showed 21 cases of solitary ulcer (77.8%), 3 cases of multiple ulcers (11.1%), 2 cases of granular proctitis (7.4%) and 1 case of pseudopolyp of rectum (3.7%). Among anorectal dynamic alterations, only 1 case (3.7%) of large rectocele was detected at endoscopy under straining. Histo-pathological changes were compared according to Rutter and Riddel criteria; the "colitis cystica profunda" appearance was observed in 2 cases (7.4%). Defecography showed 18 cases (16.6%) of solitary ulcer, 1 case (3.7%) of multiple ulcers and 2 cases (7.4%) of granular proctitis; but it missed 3 cases (11.1%) of small solitary ulcer, 2 cases (7.4%) of small multiple ulcers, and 1 case (3.7%) of pseudopolyp. The dynamic abnormalities shown by defecography were 11 cases (40.7%) of rectal intussusception, 7 cases (25.9%) of recto-anal intussusception, 6 cases (22.2%) of external rectal prolapse and 8 cases (29.6%) of mucosal prolapse. In 16 patients (59.2%) videoprotography emphasized how the ulcer wall was the first to take part in the invagination complex.

CONCLUSIONS

Double contrast barium enema represents a useful radiologic method to diagnose solitary rectal ulcer, but air insufflation and pharmacological hypotonia prevent the functional study of rectal walls. Endoscopy permits to detect mucosal ulcerations, erythema, pseudopolyps and granular proctitis; biopsy provides an accurate diagnosis. We suggest combined defecography and videoproctography as a useful tool for evaluating solitary rectal ulcer syndrome as a whole; defecography is necessary to identify associated functional abnormalities, such as rectal prolapse and intussusception, not detectable by other instrumental and radiologic investigations and considered by many authors the likely cause of the disease.

A prospective audit of the usefulness of evacuating proctography

Fifty-nine evacuating proctograms were performed over a 4 month period. We sought to identify how useful this technique is in diagnosing the cause of various anorectal symptoms and indicating which treatment option may be beneficial to the patient. The main reasons for referral were faecal soiling (60%) and obstructed defaecation (47%). Of the proctograms, 90% revealed some pathology. The most common abnormalities detected were rectocele (56%), rectal intussusception (39%), enterocele (19%) and rectal prolapse (12%). Of the patients, 45% were treated with an operation specific to the pathology detected on the proctogram; 29% did not require any active treatment and the remainder were managed with biofeedback conditioning or injection sclerotherapy. Evacuating proctography is of value in providing a diagnosis in patients with anorectal symptoms and thereby allowing specific treatment, operative or nonoperative, to be directed to the underlying pathology.

The role of parity and hysterectomy on the development of pelvic floor abnormalities revealed by defecography

OBJECTIVE

The purpose of our study was to assess the role of multiparity and pelvic surgery, especially hysterectomy, on pelvic floor dysfunction as diagnosed on defecography.

MATERIALS AND METHODS

Three hundred fifty-four women who underwent defecography between 1986 and 1996 were asked to provide information regarding obstetric history and pelvic surgery. Responses were obtained from 272 women (response rate, 77%). Their presenting symptoms ranged from incontinence to constipation and obstructed defecation. Historical data were correlated with incidence of defecographic abnormalities that included rectocele, enterocele, rectal prolapse, incontinence, excessive pelvic floor descent, and dyskinetic puborectal muscle.

RESULTS

Women with three or more birth deliveries were more likely to have incontinence (48% versus 36%, p = .05) and excessive pelvic floor descent (26% versus 17%, p = .07) than women who had delivered fewer children. Women undergoing hysterectomy before defecography were more likely to have enterocele (40% versus 25%, p = .009) and excessive pelvic floor descent (25% versus 15%, p = .04) than women who had never undergone hysterectomy.

CONCLUSION

Our findings confirm the common belief that trauma from childbirth or hysterectomy contributes to the development of defecation disorders.

Defaeco-peritoneography in the diagnosis of rectal intussusception and rectal prolapse

PURPOSE

The aim of the present study was to evaluate the use of defaeco-peritoneography in diagnosing rectal intussusception as distinct from mucosal folds in the rectum, and rectal prolapse as distinct from mucosal prolapse.

MATERIAL AND METHODS

Fifty-seven patients with defaecation disorders were examined by means of defaeco-peritoneography.

RESULTS

Twenty-three patients had rectal intussusception and 7 patients had rectal prolapse at defaeco-peritoneography. All these patients had a rectal peritoneocele in the serosal ring-pocket of the rectal intussusception or in the rectal prolapse. Twenty-seven patients had neither rectal intussusception nor rectal prolapse and none of these patients had a rectal peritoneocele.

CONCLUSION

The present study demonstrated that only patients with a rectal intussusception or rectal prolapse have a rectal peritoneocele. Defaeco-peritoneography therefore offers correct diagnosis of rectal intussusception as distinct from mucosal folds in the rectum, and of rectal prolapse as distinct from mucosal prolapse.

Laparoscopic rectopexy for complete rectal prolapse. Clinical outcome and anorectal function tests

BACKGROUND

The purpose of this study was to evaluate the clinical outcome of laparoscopic rectopexy and its effect on anorectal function investigations.

METHODS

Twelve patients with complete rectal prolapse without constipation underwent laparoscopic rectopexy. Pre- and postoperative evaluation included scoring of incontinence, anorectal manometry, and anal endosonography.

RESULTS

No recurrences of rectal prolapse were seen (median follow-up 19 months). Continence improved in eight of nine preoperatively incontinent patients. Two patients had mild constipation after surgery. Median maximum basal pressure measured by anorectal manometry increased from 20 to 25 mmHg (p = 0.005) and the rectoanal inhibitory reflex improved in seven patients (p = 0.03). Rectal sensitivity did not change significantly. Endosonography showed asymmetry and thickening of the internal anal sphincter and submucosa preoperatively. After surgery the maximum internal anal sphincter thickness decreased from 3.0 mm to 2.6 mm (p = 0.02).

CONCLUSIONS

Laparoscopic rectopexy improved continence in our patients. Anorectal function tests show a partial recovery of the internal anal sphincter. Laparoscopic rectopexy combines the low morbidity of minimal invasive surgery with the good outcome of abdominal rectopexy.

Defecography and proctography. Results of 744 patients

PURPOSE

Radiographic imaging of dynamic changes within the pelvic cavity and rectum during evacuation has been recognized as a valuable method of assessment. This study was designed to assess the incidence and clinical significance of defecographic findings in patients with possible evacuation disorders.

MATERIALS AND METHODS

All defecographic studies were reviewed by a single colorectal surgeon familiar with patients' histories and physical findings.

RESULTS

Between July 1988 and July 1995, 744 patients (566 females and 178 males) with a mean age of 63.5 (range, 12-95) years had defecographic and proctographic examination. Four hundred forty-six (60 percent) patients were diagnosed who complained of constipation, 123 (16.5 percent) of fecal incontinence, 42 (5.6 percent) of rectal prolapse, 82 (11 percent) of rectal pain, and 51 (6.9 percent) had a combination of more than one of these diagnoses. Although 93 (12.5 percent) of these evaluations were considered normal, 61 (8 percent) revealed rectal prolapse, 191 (25.7 percent) rectocele, 82 (11 percent) sigmoidocele, and 94 (12.6 percent) intussusception; in 223 (30 percent) patients, a combination of these findings was noted. Patients with paradoxical puborectalis contraction had an extremely high frequency of constipation compared with other symptoms (P < 0.0001).

CONCLUSIONS

Defecography can reveal abnormalities in the majority of patients with evacuatory disorders. There was a high incidence of rectocele, sigmoidocele, and intussusception. Care must be taken not to treat patients strictly based on radiographic findings.

[Role of radiologic diagnosis in rectal mucosal prolapse]

Defecography (DG) is a useful method to detect many morpho-functional deformities of anus and rectum and pelvic floor. We report on a clinical and radiologic study of 165 patients (36 men and 129 women) suffering from defecation disorders and rectal muscosal prolapse (RMP). All the patients had been submitted to clinical examination, endoscopy and double contrast enema to rule out organic colorectal conditions. DG was performed with a dedicated conmode and high-density barium and videorecorded on VHS cassettes to assess the dynamics of evacuation phases and to reduce exposure doses. DG showed single RMP in 28% of cases and multiple RMP in 72% of cases; the condition was isolated in 22% of cases, while in 88% of cases it was associated with other anorectal dysfunctions, such as rectocele (65%), perineal descent syndrome (PDS) (15%), puborectal muscle syndrome (14%) and intussusception (8%). RMP appeared at DG as a wall defect bulging into rectal lumen, which was more evident under straining and during barium evacuation. In 12 patients with multiple RMP, dynamic CT of the pelvis was carried out to study the whole pelvic floor and in 5 cases it showed levator ani diastasis. Fifty-eight patients were submitted to surgery by elastic binding of RMP; DG follow-up showed RMP remission in 47 patients, single RMP relapse in 3 patients and multiple RMP relapse in 3 patients. One patient with PDS and intussusception was submitted to rectopexy and mucosectom.

[The role of ultrasonic endoscopy in the examination of post-obstetrical anal incontinence]

Echoendoscopy provides a means of exploring the anorectal and neighbouring areas. The technique has been used for over 10 years in cancerology and more recently in proctology. It can be used to confirm the anatomic integrity of the anal sphincters or to identify and localize damage, making it particularly interesting for the exploration of anal incontinence. Echoendoscopy has been used in several recent series which demonstrated that besides stretch neuropathies, defects in the sphincter play a role in post-obstetrical incontinence. Whether the signs occur early or late after menopause, these ruptures are easily identified with echoendoscopy. Thus, a reliable diagnostic of the anal lesion is possible before any therapeutic decision, not only for anal incontinence but also for prolapsus or urinary incontinence. Further prospective studies should confirm the contribution of echoendoscopy in deciding on surgical repair and help determine, and thus to prevent, the risk of sphincter rupture.

Simultaneous defecography and peritoneography in defecation disorders

A number of physiologic and radiologic investigations are used in investigating defecation disorders. Defecography is one important part of these investigations. However, a correct diagnosis of an enterocele is sometimes difficult despite use of contrast media in the rectum, vagina, and small bowel.

PURPOSE

This study was undertaken to ascertain if it was technically possible to perform simultaneous defecography and peritoneography in an effort to improve the diagnostic possibilities in patients with defecation disorders.

METHODS

Twelve patients with defecation disorders and an unexplained widening of the rectovaginal space at defecography were investigated. Contrast medium was introduced intraperitoneally, after which conventional defecography was performed.

RESULTS

All investigations were carried out without complications and demonstrated the peritoneal outline in all patients. Simultaneous defecography and peritoneography differentiated between an enterocele and a pathologically deep pouch of Douglas--a peritoneocele. Three types of peritoneocele were visualized: vaginal peritoneocele, septal peritoneocele, and rectal peritoneocele with or without enterocele. Combinations of the three types were also found. Eight of the 12 patients had rectal intussusception or rectal prolapse. All of these eight patients had a rectal peritoneocele.

CONCLUSIONS

Simultaneous defecography and peritoneography can be performed without technical difficulties or complications. Peritoneal outlines and pouches can, therefore, be studied directly during the act of defecation. An unexplained widening of the rectovaginal space at defecography can be clarified as a peritoneocele, with or without an enterocele. Peritoneocele can be of three different types: rectal, septal, or vaginal.

Simultaneous dynamic proctography and peritoneography for pelvic floor disorders

PURPOSE

We sought to evaluate a new diagnostic technique for the identification of rectal and pelvic floor pathology in patients with obstructed defecation, pelvic fullness/prolapse, and/or chronic intermittent pelvic floor pain.

METHODS

Thirteen symptomatic women with either a nondiagnostic physical examination or nondiagnostic dynamic proctography (DPG) were studied. After placement of intraperitoneal and intrarectal contrast material, resting and straining pelvic x-rays were obtained in all patients, and defecation was videotaped using fluoroscopy.

RESULTS

Simultaneous DPG and peritoneography identified clinically suspected and unsuspected enteroceles in 10 of the 13 patients studied. An enterocele or other pelvic floor hernia was ruled out by the technique in three of the women studied. Rectoceles and rectal prolapse that were identified during physical examination were confirmed by DPG with peritoneography. Simultaneous DPG and peritoneography also gave a qualitative assessment of the severity and clinical significance of the identified pelvic floor disorders. Results of simultaneous DPG and peritoneography affected operative treatment planning in 85 percent of patients studied.

CONCLUSION

Simultaneous DPG and peritoneography identifies both rectal and pelvic floor pathology and provides a qualitative assessment of pelvic floor pathology severity, which allows for better treatment planning in selected patients with obstructed defecation and pelvic prolapse.

Evacuation proctography in patients with solitary rectal ulcer syndrome: anatomic abnormalities and frequency of impaired emptying and prolapse

OBJECTIVE

Solitary rectal ulcer syndrome is characterized by rectal bleeding, tenesmus, and difficult evacuation. Evacuation proctography can be used in patients with solitary rectal ulcer syndrome to diagnose associated internal or external rectal prolapse and delayed or incomplete rectal emptying. The objective of this study was to determine the proctographic abnormalities and the frequency of rectal prolapse and incomplete or delayed emptying in a large group of patients with solitary rectal ulcer syndrome.

MATERIALS AND METHODS

Proctographic examinations of 53 patients with histologically proved solitary rectal ulcer syndrome were reviewed retrospectively. Evacuation proctography was done by a standard technique. The rate and completeness of rectal emptying and structural abnormality of the rectum were recorded. Comparison was made with a control group of 20 subjects who had no anorectal symptoms.

RESULTS

Fourteen patients (26%) with solitary rectal ulcer syndrome had rectal irregularity at rest compared with none in the control group. Rectal prolapse developed on evacuation in 36 patients (68%) with solitary rectal ulcer syndrome: internal prolapse in 24 patients (45%), and external prolapse in 12 (23%). Descent of the pelvic floor on evacuation was greater in the solitary rectal ulcer syndrome group (median, 4.4 cm; range, 0-10.0 cm) than in the control group (median, 3.3 cm; range, 0.6-5.3 cm; p = .006). Thickened rectal folds were seen in 11 (55%) of 20 patients with solitary rectal ulcer syndrome examined with posteroanterior proctography. Evacuation was prolonged and incomplete in patients with solitary rectal ulcer syndrome (median, 15 sec; range, 3-60 sec) compared with control subjects (median, 10 sec; range, 3-30 sec; p = .012). All control subjects evacuated more than two thirds of the contrast material in less than 30 sec compared with only 41 patients with solitary rectal ulcer syndrome (77%). Overall, evacuation proctography disclosed delayed or incomplete emptying and/or rectal prolapse in 40 patients (75%) with solitary rectal ulcer syndrome compared with two control subjects who showed low-grade internal rectal prolapse only (p < .0001).

CONCLUSION

Solitary rectal ulcer syndrome is significantly associated with prolonged and incomplete evacuation and with an increased prevalence of internal and external rectal prolapse.

Interobserver agreement in defecography

PURPOSE

This study was designed to test the reproducibility of the diagnostic assessment of defecographies in patients with a suspected disorder of defecation.

METHODS

To evaluate interobserver agreement, 100 defecographic series of patients with complaints suggesting a disordered defecation were evaluated independently by three observers with a standardized questionnaire. After six weeks, a random sample of 35 of 100 defecographies was evaluated a second time with clinical data provided (history, proctologic examination). To evaluate whether the position of residual volume in the rectum would affect agreement, patients with substantial retention either in the upper or lower rectum were also evaluated separately.

RESULTS

Total agreement regarding rectocele and internal prolapse was 0.81 and 0.75, respectively (1.0 = complete agreement), and was significantly higher than chance agreement. Total agreement regarding residual volume in the rectum at the end of defecography and clinical relevance of findings was not different from chance agreement, providing clinical data did not significantly improve agreement. When residual volume was situated in the lower rectum, agreement regarding incompleteness of emptying and its clinical relevance was much better (0.93).

CONCLUSIONS

Interobserver agreement is good regarding the deformation of the rectum during defecography but not different from chance agreement regarding the completeness of evacuation.

Selection criteria for anterior rectal wall repair in symptomatic rectocele and anterior rectal wall prolapse

PURPOSE

This study was undertaken to determine the outcome and changes produced by an endorectal anterior wall repair in objective functional parameters using anorectal manometry and defecography and to asses their usefulness in the selection of patients for the operation.

METHODS

Between 1986 and 1990, we performed a prospective study of 76 consecutive patients with symptomatic rectocele and/or an anterior rectal wall prolapse. All patients were studied prospectively according to a fixed protocol. Standard questionnaire, defecation diary, clinical examination, defecography, and anal manometry were performed preoperatively and three to four months postoperatively.

RESULTS

Three months postoperatively, 38 patients (50 percent) had no complaints at all (excellent result), 32 (42 percent) had only a minor complaint (good result), and in 6 patients (8 percent) the complaints were essentially unchanged (unsatisfactory result). After one year, similar figures were obtained. The postoperative mean stool frequency in all patients after three months was significantly increased (P < 0.05) but not after one year. Postoperative defecographies showed a complete absence or significant diminution of the rectocele at three months and were significantly correlated with relief of symptoms. An inverse correlation was found between improvement in incontinence grade after operation and (larger) preoperative volume at which urge to defecate was elicited, making it a good predictor of improvement in incontinence by the operation.

CONCLUSIONS

The anterior rectal wall repair positively influences rectal sensation in patients with incontinence and/or obstructed defecation caused by a rectocele and/or an anterior rectal wall prolapse. Anorectal manometry was useful in studying the beneficial physiologic effects of the endorectal repair. In patients with no previous pelvic surgery, a large urge to defecate volume is a good predictor of a good clinical outcome.