Translabial ultrasound in the assessment of pelvic floor and anorectal function in women with defecatory disorders

This article shows how modern ultrasound imaging can contribute to the investigation of patients with posterior vaginal wall prolapse, obstructed defecation, fecal incontinence and rectal intussusception/prolapse, conditions that should be similarly relevant and of interest to colorectal surgeons, gastroenterologists and gynecologists. Translabial/perineal ultrasound, a simple, universally available technique, may serve as a first-line diagnostic tool in women with posterior compartment prolapse and/or symptoms of obstructed defecation, largely replacing defecation proctography and magnetic resonance proctography. This has advantages for healthcare systems, since sonographic imaging is less expensive, non-invasive, less time-consuming and does not involve radiation exposure. However, there is a substantial need for teaching that remains unmet to date. This article illustrates in details the technique of translabial ultrasonography adopted by our unit and reviews the literature supporting this method of assessing pelvic floor and anorectal function in women with defecatory disorders.     

Magnetic resonance imaging of anatomic and dynamic defects of the pelvic floor in defecatory disorders

OBJECTIVE: Endoanal ultrasound identifies anal sphincter anatomy, and evacuation proctography visualizes pelvic floor motion during simulated defecation. These complementary techniques can evaluate obstructed defecation and fecal incontinence. Our aim was to develop a single, nonionizing, minimally invasive modality to image global pelvic floor anatomy and motion. METHODS: We studied six patients with fecal incontinence and seven patients with obstructed defecation. The anal sphincters were imaged with an endoanal magnetic resonance imaging (MRI) coil and endoanal ultrasound (five patients). MR fluoroscopy acquired images every 1.4-2 s, using a modified real-time, T2-weighted, single-shot, fast-spin echo sequence, recording motion as patients squeezed pelvic floor muscles and expelled ultrasound gel; no contrast was added to other pelvic organs. Six patients also had scintigraphic defecography. RESULTS: Endoanal ultrasound and MRI were comparable for imaging defects of the internal and external sphincters. Only MRI revealed puborectalis and/or external sphincter atrophy; four of these patients had fecal incontinence. MR fluoroscopy recorded pelvic floor contraction during squeeze and recorded relaxation during simulated defecation. Corresponding comparisons for angle change and perineal descent during defecation were not significant; only MRI, but not scintigraphy, identified excessive perineal descent in two patients. CONCLUSIONS: Pelvic MRI is a promising single, comprehensive, nonradioactive modality to measure structural and functional pelvic floor disturbances in defecatory disorders. This method may provide insights into mechanisms of normal and disordered pelvic floor function in health and disease.     

Dynamic magnetic resonance imaging defecography: a diagnostic alternative in the assessment of pelvic floor disorders in proctology

PURPOSE: Standard diagnostic proctologic procedures in the assessment of pelvic floor disorders include clinical evaluation and endoscopy. Particular aspects of combined pelvic floor disorders, especially those involving more than one pelvic compartment, may remain undetected without additional technical diagnostic procedures such as videoproctoscopy, cinedefecography, or colpocystodefecography. The aim of the study was to review the potentials of dynamic magnetic resonance imaging defecography to elucidate the underlying anatomic and pathophysiologic background of pelvic floor disorders in proctologic patients. PATIENTS AND METHODS: Dynamic magnetic resonance imaging defecography was performed in 20 Patients (13 females) with main diagnoses such as rectal prolapse or intussusception, rectocele, descending perineum, fecal incontinence, outlet obstruction, and dyskinetic puborectalis muscle after clinical evaluation. The investigation was performed on a 1.5 T-magnetic resonance imaging machine in supine position. The rectum was filled with Gd-DTPA enriched ultrasound gel. First a T1/T2 weighted investigation of the pelvis was performed, followed by defecography with evacuation of the rectum. Images were obtained in a sagittal plane in a frequency of 1 image/second (true FISP) at rest and during straining. The obtained magnetic resonance imaging video tapes were analyzed off-line with cinematographic evaluation of bladder base, uterus, and anal canal position in relation to the pubococcygeal line by a blinded radiologist. Investigation time was 20 minutes. RESULTS: In dynamic magnetic resonance imaging defecography of the pelvic floor, 12 patients with descending perineum, 10 rectoceles (10 females), 6 cystoceles (6 females), 4 enteroceles (4 females), 8 intussusceptions (5 females), and a dyskinetic puborectalis muscle in 3 males were detected. In 11 females and 3 males multifocal disorders were found, involving more than one compartment in females, whereas in males complex defects were restricted to the posterior compartment. Magnetic resonance imaging defecography revealed diagnoses consistent with clinical results in 77.3 percent and defects in addition to clinical diagnoses in combined pelvic floor disorders in 34 percent. CONCLUSIONS: In complex pelvic floor disorders, involving more than a single defect, dynamic magnetic resonance imaging represents a convenient diagnostic procedure in females and to a lesser extent in males, in particular in terms of dynamic imaging of pelvic floor organs during defecation. In addition to the clinical assessment, dynamic magnetic resonance imaging had clinical impact in proctologic and interdisciplinary treatment.Presented in part at the 116th German Congress of Surgery, 1999     

Functional anorectal disorders

This report defines criteria for diagnosing functional anorectal disorders (ie, fecal incontinence, anorectal pain, and disorders of defecation). Functional fecal incontinence is defined as the uncontrolled passage of fecal material recurring for > or =3 months in an individual with a developmental age of > or =4 years that is associated with: (1) abnormal functioning of normally innervated and structurally intact muscles, and/or (2) no or minor abnormalities of sphincter structure and/or innervation insufficient to explain fecal incontinence, and/or (3) normal or disordered bowel habits (ie, fecal retention or diarrhea), and/or (4) psychological causes. However, conditions wherein structural and/or neurogenic abnormalities explain the symptom, or are part of a generalized process (eg, diabetic neuropathy) are not included within functional fecal incontinence. Functional fecal incontinence is a common, but underrecognized symptom, which is equally prevalent in men and women, and can often cause considerable distress. The clinical features are useful for guiding diagnostic testing and therapy. Functional anorectal pain syndromes include proctalgia fugax (fleeting pain) and chronic proctalgia; chronic proctalgia may be subdivided into levator ani syndrome and unspecified anorectal pain, which are defined by arbitrary clinical criteria. Functional defecation disorders are characterized by 2 or more symptoms of constipation, with > or =2 of the following features during defecation: impaired evacuation, inappropriate contraction of the pelvic floor muscles, and inadequate propulsive forces. Functional disorders of defecation may be amenable to pelvic floor retraining by biofeedback therapy (such as dyssynergic defecation).     

Laparoscopy for pelvic floor disorders

Surgical treatment of pelvic floor disorders has significantly evolved during the last decade, with increasing understanding of anatomy, pathophysiology and the minimally-invasive ‘revolution’ of laparoscopic surgery. Laparoscopic pelvic floor repair requires a thorough knowledge of pelvic floor anatomy and its supportive components before repair of defective anatomy is possible. Several surgical procedures have been introduced and applied to treat rectal prolapse syndromes. Transabdominal procedures include a variety of rectopexies with the use of sutures or prosthesis and with or without resection of redundant sigmoid colon. Unfortunately there is lack of one generally accepted standard treatment technique. This article will focus on recent advances in the management of pelvic floor disorders affecting defecation, with a brief overview of contemporary concepts in pelvic floor anatomy and different laparoscopic treatment options.     

Neurophysiological testing in anorectal disorders

Neurophysiological tests of anorectal function can provide useful information regarding the integrity of neuronal innervation, as well as neuromuscular function. This information can give insights regarding the pathophysiological mechanisms that lead to several disorders of anorectal function, particularly fecal incontinence, pelvic floor disorders and dyssynergic defecation. Currently, several tests are available for the neurophysiological evaluation of anorectal function. These tests are mostly performed on patients referred to tertiary care centers, either following negative evaluations or when there is lack of response to conventional therapy. Judicious use of these tests can reveal significant and new understanding of the underlying mechanism(s) that could pave the way for better management of these disorders. In addition, these techniques are complementary to other modalities of investigation, such as pelvic floor imaging. The most commonly performed neurophysiological tests, along with their indications and clinical utility are discussed. Several novel techniques are evolving that may reveal new information on brain–gut interactions.     

Radiologic evaluation of anorectal disorders

Defecation is a dynamic event, and although evacuation proctography does not simulate physiologic defecation exactly, it does provide maximal stress to the pelvic floor and image rectal emptying, both of which are required for the diagnosis of certain conditions: MR imaging studies are attractive in that no ionizing radiation is involved, but unless an evacuation study is performed, the features of anismus, trapping in a rectocele, and intussusception cannot be diagnosed. Because these are the main reasons for investigating difficult defecation, the fluoroscopic examination is the simplest and most reliable method. Endoanal ultrasound is an ideal screening examination for incontinence to show internal sphincter degeneration and tears of the internal or external sphincters. The diagnosis of external sphincter atrophy on ultrasound is not yet resolved, and this remains an important indication for endoanal MR imaging.     

Anal vector volume analysis: an effective tool in the management of pelvic floor disorders

Introduction  

Different trials have investigated the role of conventional anal manometry in the diagnosis of pelvic floor disorders. The aim of the present study is to define the role and the effectiveness of vector anal manometry and vector asymmetry index scoring in the assessment of pelvic floor disorders i.e. fecal incontinence and obstructed defecation.     

Funktionsdiagnostik des Kolons und Anorektums

For evaluation of functional disturbances of the colon and anorectum, diagnostic methods are available for measurement of motor activity, anorectal sensory function and evacuation. Measurement of motor activity can be achieved by colon (mostly after colonoscopic cleaning) and anorectal manometry or by barostat measurements. Anorectal manometry and barostat measurements also enable investigation of the colorectal sensory function. Intraluminal transit can be assessed with scintigraphy or by ingestion of radiopaque markers. Defecography either by conventional X-ray or magnetic resonance imaging (MRI) can be used to visualize defecation disorders. From a clinical point of view, functional disturbances of the colon and anorectum manifest themselves as chronic constipation, including defecation disorders and fecal incontinence. Both syndromes are characterized by a high prevalence and a severely disturbed quality of life. Diagnostic evaluation should be initiated if a trial therapy fails. Colonic transit time measurement, defecography, and anorectal manometry are indicated for evaluation of chronic constipation, while anorectal manometry, anal endoscopic ultrasound, sphincter electromyogram (EMG), and if necessary, investigation of diarrhea are required for fecal incontinence.     

Obstructive Defecation in Middle-aged Women

Obstructive defecation, a significant contributor to constipation, is frequently reported in middle-aged women, yet few population-based studies have established prevalence in this group. We analyzed data from the Reproductive Risks for Incontinence Study at Kaiser, a population-based cohort of racially diverse women, 40-69 years old, to describe the prevalence of obstructive defecation and identify associated risk factors. The Reproductive Risks for Incontinence Study at Kaiser is a randomly selected cohort of 2,109 women in the Kaiser Medical System. Obstructive defecation, determined by self-report, was defined as difficulty in passing stool, hard stool, straining for more than 15 min, or incomplete evacuation, occurring at least weekly. Age, race, income, education, drinking, health status, parity, pelvic organ prolapse, urinary incontinence, number of medications, hysterectomy, surgery for pelvic organ prolapse, colectomy, irritable bowel syndrome, and body mass index were assessed for both their univariate and multivariate association with obstructive defecation. Multivariate logistic regression was used to determine the independent association between associated factors and the primary outcome of obstructive defecation. Obstructive defecation that occurred at least weekly was reported by 12.3% of women. Significant independent risk factors included irritable bowel syndrome [odds ratio 1.78, (95% confidence interval 1.21-2.60)], vaginal or laparoscopic hysterectomy [2.01 (1.15-3.54)], unemployment [2.33 (1.39-3.92)], using three or more medications [1.81 (1.36-2.42)], symptomatic pelvic organ prolapse [2.34 (1.47-3.71)], urinary incontinence surgery [2.52 (1.29-4.90)], and other pelvic surgery [1.35 (1.03-1.78)]. We concluded that obstructive defecation is common in middle-aged women, especially those with a history of treatment for pelvic floor conditions. Women who had undergone laparoscopic/vaginal hysterectomies or surgery for pelvic organ prolapse or urinary incontinence had a nearly two times greater risk of weekly obstructive defecation. Demographic factors, with the exception of employment status, were not significant, indicating that obstructive defecation, although widespread, does not affect any particular group of women.     

Rectocele: pathogenesis and surgical management

BACKGROUND: Rectocele is a common finding in patients with intractable evacuatory disorders. Although much rectocele surgery is conducted by gynecologists en passant with other forms of vaginal surgery, many reports lack appreciation of the importance of coincident anorectal symptoms, and do not report functional and clinical outcome data. The pathogenesis of rectocele is still controversial, as is the embryological and anatomical importance of the rectovaginal septum as well as recognizable defects in its integrity and its relevance in formal repair when rectocele is operated upon as the principal condition in patients with intractable evacuatory difficulty. DISCUSSION: The investigation and surgical management of rectocele is controversial given the relatively small numbers of operated patients in any single specialist unit and the relative lack of prospective data concerning functional outcome in operated cases. The imaging of rectocele patients is currently in a state of change, and the newer diagnostic modalities including dynamic magnetic resonance imaging frequently display a multiplicity of pelvic floor disorders. When surgery is indicated, coloproctologists most commonly utilize an endorectal defect-specific repair, but there are few controlled randomized data regarding outcome and response criteria of specific symptoms with particular surgical approaches. A Medline-based literature search was conducted for this review to assess the clinical results of defect-specific rectocele repairs using the endorectal, transvaginal, transperineal, or combined approaches. Only the studies are included that report both pre- and postoperative symptoms including constipation, evacuatory difficulty, pelvic pain, the impression of a pelvic mass, fecal incontinence, dyspareunia or the need for assisted digitation to aid defecation. CONCLUSION: The history of rectocele repair, its clinical and diagnostic features and the advantages, disadvantages and indications for the different surgical techniques are presented in this review. Suggested diagnostic and surgical therapeutic algorithms for management have been included. It is recommended that a multicenter controlled randomized trial comparing surgical approaches for symptomatic evacuatory dysfunction where rectocele is the principal abnormality should be conducted.     

Chronic perineal pain: current pathophysiological aspects, diagnostic approaches and treatment

Chronic perineal pain is the anorectal and perineal pain without underlying organic disease, anorectal or endopelvic, which has been excluded by careful physical examination, radiological and endoscopic investigations. A variety of neuromuscular disorders of the pelvic floor lead to the different pathological conditions such as anorectal incontinence, urinary incontinence and constipation of obstructed defecation, sexual dysfunction and pain syndromes. The most common functional disorders of the pelvic floor muscles, accompanied by perineal pain are levator ani syndrome, proctalgia fugax, myofascial syndrome and coccygodynia. In the diagnosis of these syndromes, contributing to a thorough history, physical examination, selected specialized investigations and the exclusion of organic disease with proctalgia is carried out. Accurate diagnosis of the syndromes helps in choosing an appropriate treatment and in avoiding unnecessary and ineffective surgical procedures, which often are performed in an attempt to alleviate the patient's symptoms.     

Kombinierte Stuhl- und Harninkontinenz

Background: Double (urinary and fecal) incontinence is relatively common in the elderly. 6% of men and 9.5% of women over 50 years suffer from combined urinary and fecal incontinence. 50% of males and 60% of females with fecal incontinence have concurrent urinary incontinence. The high rate of concurrence of urinary and fecal incontinence is due to an almost identical innervation of the urinary bladder and the rectum and the close vicinity and partial identity of the muscular sphincter mechanisms. Classification: There are two causal entities of double incontinence: 1. neurogenic disorders, 2. pelvic floor dysfunction. Neurogenic disorders can be classified in central and peripheral nervous lesions. Pelvic floor dysfunction can be due to nerve injury or direct muscular lesions. According to the International Continence Society, urinary incontinence is classified into five categories: 1. stress incontinence, 2. urge incontinence, 3. reflex incontinence, 4. overflow incontinence, 5. extraurethral incontinence. With respect to anal incontinence, the first four groups are important. Diagnosis: The diagnostic evaluation comprises meticulous history, physical examination including neuro-urological status, rectal and in females standardized pelvic examination, urinalysis, sonography of the kidneys and bladder after voiding (postvoid residual urine). In women, a transrectal ultrasound of the bladder, urethra and the pelvic floor is important and can replace lateral cystourethrography. In complex cases, dynamic NMR imaging is helpful. Functional investigations include urodynamic studies with uroflowmetry, filling and voiding cystometry and urethral pressure profiles and rectomanometry. Conclusion: For optimal therapy of double incontinence, an interdisciplinary approach is necessary.     

Anorectal incontinence: therapeutic strategy of a complex surgical problem

The anatomophysiological integrity of the pelvic floor and anorectum contributes to the important function of continence and defecation. A variety of causes can cause damage in the anatomy and/or the innervation of the pelvic floor muscles as well as in anorectal sensitivity or stool consistency leading to anorectal continence disorder and incontinence. The most common cause of anorectal incontinence is related to injury of the sphincter muscles after delivery, or anorectal surgery. Anorectal incontinence is a complex problem, often of multifactorial origin. The exact cause of its incidence is unknown. However, the incidence is approximately 2% in the general population and 25-60% in the elderly. Although the condition is considered a problem in the elderly, it is becoming apparent that people are frequently affected from a much younger age. Anorectal incontinence is a severe disability and a major social problem as it produces a feeling of insecurity and pushes the patient towards social isolation. Management of the incontinent patient may be conservative (medicinal, biofeedback training), surgical (sphincter repair, pelvic floor repair, neosphincter formation, artificial sphincter or stoma) or use sacral nerve stimulation. The successful treatment of anorectal incontinence depends on accurate diagnosis of its cause, which is achieved by a thorough patient assessment including patient history, physical examination and selective specialized investigations. A stoma is the final resort when all other therapeutic attempts have failed.     

Urodynamic evaluation of the bladder and pelvic floor

Pelvic floor disorders including lower urinary tract dysfunction are common, and may be evaluated by urodynamic tests, such as cystometry, uroflowmetry, pressure flow studies, electromyography, and video-urodynamics. These urodynamic tests provide objective information regarding the normal and abnormal function of the urinary tract and pelvic floor, and provide a better understanding of the pathophysiologic processes that cause lower urinary tract symptoms. This article describes typical urodynamic studies and their roles in the evaluation of common pelvic floor disorders, including stress urinary incontinence, overactive bladder, and pelvic organ prolapse.     

The physiology of human defecation

Human defecation involves integrated and coordinated sensorimotor functions, orchestrated by central, spinal, peripheral (somatic and visceral), and enteric neural activities, acting on a morphologically intact gastrointestinal tract (including the final common path, the pelvic floor, and anal sphincters). The multiple factors that ultimately result in defecation are best appreciated by describing four temporally and physiologically fairly distinct phases. This article details our current understanding of normal defecation, including recent advances, but importantly identifies those areas where knowledge or consensus is still lacking. Appreciation of normal physiology is central to directed treatment of constipation and also of fecal incontinence, which are prevalent in the general population and cause significant morbidity.     

Reinterventions after complicated or failed STARR procedure

Background/aims  The stapled transanal rectal resection (STARR) procedure has been suggested as a simple surgical option for patients presenting with evacuatory difficulty in the clinical presence of a rectocele. Most of these patients have a multiplicity of pelvic floor pathology unaddressed by the performance of one procedure. The aim of the study was to assess an unselected group of patients referred to a tertiary coloproctological unit following performance of the STARR procedure for obstructed defecation (OD) where the procedure was complicated or had failed. Materials and methods  Anorectal, urogynecological, and psychological examination with objective constipation/incontinence scoring, anal–vaginal–perineal ultrasound, manometry, and defecography were selectively performed utilizing the Iceberg Diagram to detect occult pelvic floor pathology. Results  Twenty patients were referred with 13 cases (female, 10; median age, 65 years; range, 40–72) operated upon. Post-STARR surgery was performed for three complications and ten failures including recurrent OD, severe proctalgia, and fecal incontinence. Overall, 11 patients underwent biofeedback therapy and psychotherapy. Of the operated group, 11 patients had a median of four associated disorders. Seven patients had a significant psychological overlay with severe depression or anxiety and four heterogeneous anal sphincter defects. Operative procedures were tailored to the clinical findings using enterocele repair, staple removal, fistulectomy, rectosigmoid resection, and levatorplasty where appropriate. Twelve patients were evaluated after a median follow-up of 18 months. Of these, six (all with psychoneurosis) remained unchanged. Three patients with no psychological overlay were asymptomatic with a further two improved. Conclusion  The STARR procedure, when complicated or failed, has a poor outcome following surgical reintervention. It requires careful patient selection to determine the associated pelvic floor pathology and pre-existent psychopathology.     

The role of biofeedback in the treatment of gastrointestinal disorders

Biofeedback is a form of treatment that has no adverse effects and can be provided by physician extenders. The therapy relies on patients' ability to learn how to influence their bodily functions through dedicated machinery and teaching. This Review provides a comprehensive overview of all potential therapeutic applications of biofeedback for functional constipation, fecal incontinence, functional anorectal pain, IBS, functional dyspepsia, and aerophagia. Practical clinical applications of biofeedback therapy supported by randomized, controlled trials (RCTs) are limited to fecal incontinence and dyssynergic defecation. For fecal incontinence, RCTs suggest that biofeedback combining strength training and sensory discrimination training is effective in approximately 75% of patients and is more effective than placebo. However, verbal feedback provided by a therapist during extended digital examination may be equally effective, and children whose fecal incontinence is associated with constipation plus fecal impaction do no better with biofeedback than medical management. For dyssynergic defecation, RCTs show that biofeedback combining pelvic floor muscle relaxation training, practice in defecating a water-filled balloon, and instruction in effective straining is effective in approximately 70% of patients who have failed to respond to laxative treatment. For both incontinence and dyssynergic defecation, the benefits of biofeedback last at least 12 months.     

Assessing and treating pelvic organ prolapse

At least half of all women who have given birth experience pelvic organ prolapse, a condition where pelvic organs protrude through the vagina. Because of the presentation of the different aspects of prolapse, treatment had become compartmentalized in line with pelvic involvement, with urologists, gynecologists, colorectal surgeons, and gastroenterologists each addressing their field of expertise. In addition, urinary or fecal incontinence, urinary retention, and urinary tract infections often are associated with pelvic organ prolapse. Both pelvic organ prolapse and incontinence have a significant impact on the quality of life. New training programs in urogynecology and reconstructive pelvic surgery are producing clinicians who are better equipped to treat pelvic organ prolapse, as well as related urinary and fecal incontinence. This article provides an overview of the various aspects of pelvic organ prolapse for all clinicians involved in assessment, treatment, and potential prevention of this condition.     

Diagnosis of disturbances of continence and defecation

Defecography was performed in 60 patients with disorders of continence or defecation in whom previous investigative procedures had not revealed any abnormality that could explain the disorder. A correct diagnosis was made in 47 patients (78%). Defecography appears to be a suitable procedure to detect functional disturbances of defecation. Since anterior rectal wall abnormalities such as colitis cystica profunda and solitary rectal ulcer were seen in eight patients, is in suggested that these abnormalities are a result of functional disorders of defecation. Furthermore, the function of the pelvic floor musculature can be assessed by defecography in order to determine the cause of fecal incontinence. Read at the joint meeting of the American Society of Colon and Rectal Surgeons, the Section of Colo-Proctology of the Royal Society of Medicine, and the Section of Colonic and Rectal Surgery of the Royal Australasian College of Surgeons, New Orleans, Louisiana, May 6 to 11, 1984.