A novel two-dimensional dynamic anal ultrasonography technique to assess anismus comparing with three-dimensional echodefecography

Objective  The aim of this prospective study was to test two-dimensional dynamic anorectal ultrasonography (2D-DAUS) in the assessment of anismus and compare it with echodefecography (ECD).
Method  Fifty consecutive female patients with outlet delay were submitted to 2D and 3D-DAUS, measuring the relaxing or contracting puborectalis muscle angle during straining. The patients were assigned to one of two groups based on ECD findings. Group I consisted of 29 patients without anismus and group II included 21 patients diagnosed with anismus. Subsequently 2D-DAUS images were checked for anismus and compared with ECD findings.
Results  Upon straining, the angle produced by the movement of the puborectalis muscle decreased in 26 out of the 29 (89.6%) patients of group I and increased 19 out of the 21 (90.4%) patients of group II. The mean angle during straining differed significantly between group I and group II. The index of agreement between the two scanning modes was 89.6% (26/29) for group I (Kappa: 0.796; CI: 95%; range: 0.51–1.0) and 90.4% (19/21) for group II (Kappa: 0.796; CI: 95%; range: 0.51–1.0).
Conclusion  Two-dimensional dynamic anal ultrasonography can be used as an alternative method to assess patients with anismus, although the 3-D modality is more precise to evaluate the PR angle as the sphincters integrity as the whole muscle length is clearly visualized.     

Experience of posterior division of the puborectalis muscle in the management of chronic constipation

Nine women with severe chronic constipation who were unable to expel a water-filled rectal balloon underwent posterior division of the puborectalis muscle. Pre-operative concentric needle electromyography and measurement of the anorectal angle at rest and during straining suggested that the puborectalis muscle failed to relax during attempted defaecation in these patients. Two patients reported improvement after surgery and had normal balloon expulsion after operation. However seven patients reported no benefit from surgery and tests of defaecatory function and anorectal angle did not change. Incontinence for solid stool was not reported following puborectalis muscle division although five patients reported incontinence of flatus, liquid stool and mucus.     

儿童盆底失弛缓综合征的诊断与治疗

目的探讨儿童盆底失弛缓综合征的诊断与治疗。方法对2001年11月至2004年11月间29例便秘患儿经结肠造影和直肠肛门测压诊断为盆底失弛缓综合征的临床资料进行回顾性分析。结果本组男13例,女16例,年龄(6．7±4．0)岁。所有病例经过结肠造影和直肠肛门抑制反射(RAIR)检查均排除先天性巨结肠症。29例患儿排便弛缓反射均为上升相(正常为下降相),RAIR正常(注气5～10 m1)21例,RAIR减弱(注气15～30 ml)8例；20例直肠初始感觉和最大耐受量均正常。明确诊断后采用排便诱导训练法,配合饮食调节、乳果糖或福松等缓泻剂软化大便等治疗1-2个月,痊愈4例,好转5例,有效率31．0%；开塞露依赖20例。有4例病史在1年以上、长期依赖开塞露的学龄期患儿做了肛门内括约肌和直肠平滑肌部分切除术(Lynn术),术后随访5—24个月,平均每1-2日自行排便1次,疗效满意；其中2例术后复查直肠肛门测压、肛管静息压及括约肌功能长度均较术前下降,排便弛缓反射仍为上升相。结论儿童盆底失弛缓综合征的诊断主要依据便秘病史、结合直肠肛门测压和结肠造影；排便诱导训练法等治疗不满意者可选择Lynn术。     

Anismus in patients with normal and slow transit constipation

This study examined differences in anorectal function, with particular reference to anismus, which might explain why some patients with intractable constipation have slow and others have normal whole gut transit times. Twenty-four patients were studied; 13 with slow transit (all female, median age 32 years, range 16-52 years) and 11 with normal transit (eight women, three men, median age 37 years, range 21-60 years). Videoproctography with synchronous sphincteric electromyography and anorectal manometry was performed. There were no differences between the two groups, suggesting that slow transit constipation is not secondary to any abnormality in anorectal function and may therefore be a primary disorder of colonic motility. There was no correlation between electromyographic evidence of anismus (pelvic floor contraction on defaecation) and the ability of the patient to evacute the rectum or symptoms of obstructed defaecation. Electromyography findings alone can be misleading and should be related to proctographic evidence of incomplete rectal evacuation before functional anismus can be said to be present.     

Comparison of the Q-tip test and voiding cystourethrogram to assess urethral hypermobility among women enrolled in a randomized clinical trial of surgery for stress urinary incontinence

PURPOSE: We compared 2 measures of urethral hypermobility, the Q-tip test and voiding cystourethrogram, preoperatively in women recruited in 1 center participating in a multicenter randomized clinical trial comparing Burch colposuspension with autologous rectus fascia sling. MATERIALS AND METHODS: Following institutional review board approval, women with stress urinary incontinence and pelvic organ prolapse stage 2 or less underwent a standardized standing voiding cystourethrogram and a Q-tip test at a 45 degree angle reclining position preoperatively. Urethral angle at rest and straining were measured with a radiological ruler (voiding cystourethrogram) or goniometer (Q-tip) by 2 different investigators blinded to each other findings. RESULTS: In 43 patients the mean urethral angle at rest and UAS were 20 degrees +/- 12 and 51 degrees +/- 20, by voiding cystourethrogram compared to 16 degrees +/- 9 and 58 degrees +/- 10 by Q-tip test, respectively. The mean angle difference (urethral angle with straining minus urethral angle at rest) was greater for the Q-tip test (42 degrees +/- 9) than that for the voiding cystourethrogram test (32 degrees +/- 17; p < 0.05). Fewer patients (14% by Q-tip, 28% by voiding cystourethrogram) had urethral hypermobility using the definition of urethral angle at rest greater than 30, while almost all patients (91% by voiding cystourethrogram, 100% by Q-tip) had urethral hypermobility using the definition of urethral angle with straining greater than 30. However, using the definition of urethral angle with straining minus urethral angle at rest greater than 30, only 58% of patients had urethral hypermobility by voiding cystourethrogram compared to 98% by Q-tip. CONCLUSIONS: The voiding cystourethrogram and the Q-tip test measure urethral hypermobility differently. This may affect which patients are classified as having urethral hypermobility, and the choice of anti-incontinence surgery.     

盆底失弛缓综合征患者肛管直肠动力学改变与便秘关系的研究

为探讨盆底失弛缓综合征患者肛管直肠动力学改变与便秘的关系,本研究采用多导单囊肛管直肠功能测定仪对30例盆底失弛缓综合征患者的肛管直肠压力、直肠感知阈值、直肠最大耐受量和肛管一直肠抑制阈值进行检测,并与正常人进行对比分析。结果显示,与正常人相比,盆底失弛缓综合征患者的肛管舒张压降低,肛管静息压、直肠静息压、肛管最大收缩_压、直肠感知阈值、直肠最大耐受量及肛管一直肠抑制阈值均增高,差异均有统计学意义,P〈0．05。结果表明,盆底失迟缓综合征患者的肛管直肠动力学改变可能是形成便秘的原因之一。     

Manometry studies in the evaluation of anal continence

In a complex measuring program performing anorectal perfusion manometry a great number of parameters were determined in incontinent patients, patients after continence improving operations and in healthy persons. In this way, we were able to select 20 parameters in which healthy persons differ from incontinent patients, the difference occurring with a security of 99.0 to 99.9%. Our investigations were carried out with test persons at rest, after distension of the rectal ampulla, during abdominal straining and coughing. Rectoanal resting profiles and stress profiles were recorded and the measuring values obtained compared with an anamnestic score.     

THE ANORECTAL ANGLE IS NOT A RELIABLE PARAMETER ON DEFAECATING PROCTOGRAPHY

Proctography is a standard method of investigating anorectal disorders. The parameters derived from this X-ray include the anorectal angle. The reproducibility of this measurement was assessed in 43 defaecating proctograms viewed by four observers on two separate occasions. Measurements were made at rest and during defaecation straining. Significant intra- and inter-observer variation was found. The anorectal angle is an inaccurate measurement, and should be interpreted with caution.     

The balloon proctogram

A balloon filled with barium has been used to simulate a soft stool for the radiological study of disorders of defaecation. Lateral radiographs demonstrate the level of the pelvic floor in relation to the pubococcygeal line, the change in the anorectal angle and the behaviour of the anal sphincters. In 12 patients with faecal incontinence, successfully treated surgically by postanal sphincter repair, the anorectal angle was reduced from 135 degrees +/- 4.4 degrees (s.e.m.) to 103 degrees +/- 4.1 degrees and the anorectal junction rose by 1.5 +/- 0.4 cm. In 10 patients with slow-transit constipation there was no pelvic descent and no change in the anorectal angle on straining. These patients were unable to expel the balloon and the results suggest that the pelvic floor does not relax normally.     

Faecal incontinence: manometric and radiological changes following postanal repair

Ten patients with idiopathic faecal incontinence underwent postanal repair based on clinical assessment of their symptoms. Their manometric and radiological values before surgery were compared with values from 10 normal volunteers and then the changes following surgery were examined and correlated with the clinical results. Anal manometry was performed using a multilumen, low compliance, perfused catheter system. Anorectal angles and perineal descent were established radiologically. Pre-operative manometry demonstrated significant reduction in maximum and squeeze pressure (median 77 mmHg versus 200 mmHg), the volume required to inhibit the rectoanal reflex (median 40 mL versus 70 mL), and the volume retained in the saline continence test (median 400 mL versus 1500 mL). The majority of patients had obtuse anorectal angles (six of 10 at rest), and abnormal perineal descent (eight of 10 on straining). Nine patients have been improved clinically following surgery. Postoperative manometry and radiology have been performed in seven patients and have shown no significant changes. Anal manometry and radiology are objective means of documenting faecal incontinence although their role in selecting patients for surgery is not yet determined. Postanal repair is effective in restoring continence, although the parameters measured have not explained the mechanism of this effect.     

Scintigraphic assessment of the anorectal angle in health and after ileal pouch-anal anastomosis.

To determine whether the anorectal angle was preserved after ileal pouch-anal anastomosis, a simple, safe, low-radiation, real-time method of imaging the anorectum was developed. A cylindrical balloon was placed in the neorectum and anal canal and filled with a solution of 99mTc in water. A gamma camera then imaged the angulation of the balloon while the subject was at rest, during sphincteric squeeze, and during a Valsalva maneuver. Thirteen healthy volunteers and six patients were studied after ileal pouch-anal anastomosis. An angle was identified in all controls and patients. In the lateral decubitus position at rest, the mean anorectal angle in controls (102 +/- 18 degrees; SD) and anopouch angle in patients (108 +/- 19 degrees) were similar (p = 0.3). Sitting straightened the angle in both groups (p less than 0.03), whereas sphincteric squeeze and a Valsalva maneuver sharpened the angle in both the sitting and standing positions (p less than 0.03). In the lateral decubitus position, however, the pouch group was less able to sharpen the angle than were the controls (p = 0.04). In controls, the anorectal junction descended during sitting and elevated during squeeze (p less than 0.03), but this did not occur in the pouch group. In conclusion, maneuvers favoring or stressing continence (squeeze, Valsalva) sharpened the anorectal angle and elevated the pelvic floor, whereas a maneuver favoring defecation (sitting) straightened the angle and caused the pelvic floor to descend. After ileal-anal anastomosis, the angle and its movements (except those while lying) were similar to controls. Elevation of the pelvic floor during squeeze, however, was decreased, indicating a decreased mobility of the pelvic floor after operation.     

Prospective study of the effects of postanal repair in neurogenic faecal incontinence

The most important factor associated with a good result in the surgical treatment of neurogenic faecal incontinence by postanal repair is considered to be restoration of the obtuse anorectal angle. Sixteen patients (14F:2M; median age 59 years) with neurogenic faecal incontinence confirmed by a raised fibre density in the external anal sphincter underwent postanal repair. Pre- and postoperative manometric assessment was performed in 16 and radiological assessment in 12. Normal ranges for these parameters were established in age and sex matched control subjects. Continence was improved in 14 (88 per cent) patients, 6 (38 per cent) of whom regained normal continence, at a minimum of 15 months follow-up. A successful outcome was associated with no significant change in basal (pre-operative 35 (10-85) cmH2O, postoperative 44 (12-105) cmH2O; n.s.) or voluntary (pre-operative 43 (5-150) cmH2O, postoperative 32 (12-180) cmH2O; n.s.) components of anal canal pressure. There was a small but significant increase in sphincter length (pre-operative 2 (0-3) cm, postoperative 2.5 (0-3.5) cm; P less than 0.01). There was no significant change in the anorectal angle at rest (pre-operative 96 (90-110) degrees, postoperative 107 (79-118) degrees; n.s.) in the patients in whom continence was restored and five of these patients had resting anorectal angles within the normal range (75-94 degrees). Thus postanal repair need not be restricted to patients with widening of the anorectal angle since its beneficial effects do not appear to be related to reduction of this angle.     

DYNAMIC DISPLACEMENT CHANGES OF THE BLADDER NECK WITH THE PATIENT SUPINE AND STANDING

Purpose

With the patient standing and supine we determine the differences in dynamic changes of the bladder neck and directions of dynamic bladder neck displacement.

Materials and Methods

To evaluate the dynamic movement of the bladder neck we recruited into the study 78 consecutive women 27 to 69 years old with various urogynecological complaints. The anatomical changes of the bladder neck from rest to maximal straining and from rest to holding were evaluated and compared with the patients supine and standing.

Results

Except for bladder neck rotational angle with the patient standing, all parameters were significantly different from corresponding measurements with the patient supine. Mean rotational angle of rest to maximal straining plus or minus standard deviation was 39.4 +/− 18.9 degrees when standing versus 39.8 +/− 23.4 degrees when supine (p >0.05). The distances between the bladder neck and symphysis pubis at rest, and during maximal straining and holding the bladder neck in the supine position were significantly longer than those in the standing position. The direction of bladder neck displacement from rest to maximal straining was more caudal and ventral when standing. The bladder neck moved cephalad and ventral when the patient was standing, and cephalad and dorsal with the patient supine and holding the bladder neck.

Conclusions

The anatomical locations and dynamic displacements of the bladder neck at rest, and during maximal straining and holding were significantly different in the supine and standing positions. While evaluating the dynamic motion of the bladder neck to determine bladder neck mobility, patient position must be considered and specified in accordance with diagnostic standards.     

A rare condition of anorectal dysfunction in a patient with multiple sclerosis: Coexistence of faecal incontinence and mechanical constipation: Report of case

INTRODUCTION

Multiple sclerosis is a chronic demyelinating neurological disease and causing a variety of neurological symptoms, including discomfort of anorectal function. Constipation and faecal incontinence present as anorectal dysfunction in MS and anal manometry, colonic transit time, electromyography, and defecography can be used for assessment.

PRESENTATION OF CASE

We presented a thirty-three years old woman with rare condition of anorectal dysfunction in multiple sclerosis. Anal manometry, defecography were done, and synchronously anal incontinence and mechanical constipation due to rectocele and anismus were detected in this patient.

DISCUSSION

Although anal incontinence and constipation are seen often in patients with multiple sclerosis, in the literature, coexistence of animus, rectocele and anal incontinence are quite rare.

CONCLUSION

Defecography and anal manometry are useful diagnostic methods for demonstration of anorectal dysfuntions in patients with MS.     

Study of the role of the second defecation reflex: anorectal excitatory reflex in the pathogenesis of constipation

BACKGROUND: Previous studies have shown that anal distension caused rectal contraction, an action mediated through the anorectal excitatory reflex. Anal anesthetization aborted rectal contraction and rectal evacuation was induced by excessive straining. We investigated the hypothesis that inhibition or absence of the anorectal excitatory reflex could lead to constipation. METHODS: We studied 18 patients (mean age +/- SD: 40.6 +/- 5.8 years, 14 women) with rectal inertia, 14 (41.7 +/- 6.6 years, 12 women) with puborectalis paradoxical syndrome, and 10 healthy volunteers (37.9 +/- 4.8 years, 8 women). The rectum was filled with normal saline until urge and then evacuated; residual fluid was calculated. The anal and rectal pressure response to anal balloon distension in increments of 2 mL of saline was recorded by a two-channel microtip catheter. RESULTS: In the healthy volunteers, saline was evacuated as a continuous stream without straining except occasionally at the start of evacuation; no residual fluid was encountered. Anal balloon distension effected notable rectal pressure increase. In rectal inertia patients, evacuation occurred in small fluid gushes produced with excessive straining; residual fluid of large volume was collected. Anal balloon distension up to 10 mL produced no notable rectal pressure changes. The patients with PPS failed to evacuate more than a few mL of fluid despite excessive straining; the volume of residual fluid was considerable. Anal balloon distension caused a notable rectal pressure rise. The results were reproducible. CONCLUSIONS: These results suggest that the defecation reflexes (rectoanal and anorectal) are absent in rectal inertia patients and this presumably denotes a neurogenic disorder. The anorectal reflex is active in puborectalis paradoxical syndrome, but the rectoanal reflex is not, indicating a possible myogenic defect in the puborectalis muscle.     

Urodynamic and rectomanometric findings in patients with spinal cord injury

Patients with spinal cord lesion suffer from complex disorders of bladder and anorectal function. We assessed the value of urodynamics and anorectal manometry as prognostic and diagnostic tools in these patients and evaluated the usefulness of these techniques for the differentiation between complete and incomplete spinal cord lesions. Thirty patients with suprasacral spinal cord injury (six women, 24 men; mean age, 31 years) underwent anorectal manometry and urodynamics within the first 40 days after injury. The findings were compared to the results of a clinical neurologic evaluation. Fifteen patients were classified as complete lesions on their clinical signs, three of these lesions were incomplete according to urodynamic testing and five were incomplete according to visceral sensory testing by anorectal manometry. Despite significant differences in maximum bladder capacity (589 versus 465 mL), maximum detrusor pressure (18 versus 31 cm H2O) was not significantly different between patients with complete and patients with incomplete spinal cord injury. Anorectal manometry did not reveal any significant differences in resting pressure, abdominal pressure, and maximal rectum volume between these groups. Urodynamics and anorectal manometry may be superior to neurologic assessment of completeness of spinal cord lesions. Urodynamics and anorectal manometry were not helpful in the prediction of onset or severity of detrusor hyperreflexia. Thus, we do not regard anorectal manometry as a standard diagnostic tool in spinal cord injury patients.     

Outpatient measurement of perineal descent.

One hundred and fifty-eight consecutive patients attending a rectal clinic have undergone measurement of perineal descent at rest and during straining by a simple noninvasive method. In nine patients (5.7%) the perineum was assessed as being below the ischial tuberosities at rest, whilst a further nine patients (5.7%) had abnormal descent (greater than 2.5 cm) during straining. Sixteen of the 18 patients with abnormal descent at rest or on straining were female and in ten (56%) a diagnosis of haemorrhoids was made at the initial clinic attendance. Parity of four or more was associated with a greater degree of descent during straining (P less than 0.05) than in women having a single pregnancy only.     

Combined parasacral, vaginal and endorectal approach in surgical treatment of giant rectocele

Authors operated on their Surgical departement 67 years old women with incomplete evacuation, and digital support during defecation, giant rectocele and massive vaginal vault prolaps. Authors realized cinedefecography and detected giant rectocele, depth was 8 cm, anorectal angle was 120 degrees. They stated Resting pressure 40 cm H2O, and Maximum squeeze pressure 50cm H2O by anorectal manometry. Authors verified external anal sphincters defect by endoanal ultrasound and determined Pudendal nerve terminal motor latency (PN TML) and recorded pathologic values of n.pudendal latency ( left branch 2,7 msec., right branch 4,3 msec). In concerning massive vaginal vault prolaps, huge rerectocele and clinical incompletely evacuation with self digital support during defecation with present defect od external anal sphincters and pathologic values of PN TML, authors indicated and made combined transvaginal, endorectal and perineal reconstructive operative performance. In the present time two years after the surgery radiologic mean depth of the rectocele was significantly reduced (preoperatively 8cm; postoperatively 1 cm). Anorectal angle is 100 degrees. Values of the PN TML is normaly (left branch of n. pudendalis 1,7 msec and right branch of n. pudendalis 1,9 msec). Authors recorded Resting pressure 60 cm H2O and Maximum squeeze pressure 110 cm H2O by anorectal manometry. They didnt visualized any external anal sphincters defect by anal ultrasound. Postoperatively difficult evacuation completely disappeared and digital support was no longer necessary during evacuation.     

Clinical examination remains more important than anorectal function tests to identify treatable conditions in women with constipation

Introduction and hypothesis

Many women with chronic constipation are referred for anorectal function tests (AFT) when they fail initial conservative treatment with lifestyle advice and laxatives. Our goal was to prospectively investigate the diagnostic potential of AFT in women with constipation in order to identify treatable conditions.

Methods

Between May 2003 and June 2011, all women with constipation referred to our tertiary referral center completed a questionnaire regarding their perianal complaints and underwent physical examination and were evaluated according to our AFT protocol, including anorectal manometry (ARM) and anal endosonography.

Results

One hundred and thirteen women were referred and classified as having idiopathic constipation (n?=?100), neurological disorder (n?=?8), or others (n?=?5). Of the 100 women with idiopathic constipation, clinical examination identified 25 (25 %) with hypertonia of the pelvic floor (dyssynergic pelvic floor) and 15 (15 %) with a rectocele. In 37/100 women also complaining of impaired evacuation, the yield of rectocele was 15 (41 %) and of hypertonia 5 (14 %). Women with hypertonia were younger (40 vs. 51 years; P?=?0.002) and had no rectoceles identified (P?=?0.02), and fewer women could relax during straining on ARM (56 % vs. 92 %; P?<?0.001) compared with women without pelvic hypertonia. Other ARM measurements showed no differences between women with evacuation disorders, rectoceles, or hypertonia. Anal endosonography showed no internal sphincter hypertrophia.

Conclusion

Potentially treatable conditions, such as rectocele and pelvic floor hypertonia, are found on clinical examination in 40 % of women with idiopathic constipation. Impaired evacuation is associated with the presence of a rectocele. AFT contributes little and should be reserved for selected cases.     

New method for the dynamic assessment of anorectal function in constipation

A new dynamic technique for the investigation of anorectal function has been developed. This involves radiological visualization of the rectum during voiding of a semisolid radio-opaque contrast medium, and simultaneous measurement of the intrarectal pressure and electrical activity of the external anal sphincter. The method has been used to study patients (n = 16) with profound difficulty passing formed stool. It has demonstrated an abnormal increase in the activity of the puborectalis and superficial and sphincter muscles during voiding in these patients, compared with normal subjects (n = 6). The inability to void was associated with failure to widen the anorectal angle on straining.