Perineal descent and levator ani hernia: a dynamic magnetic resonance imaging study

PURPOSE: Patients with symptomatic pelvic organ prolapse often have multifocal pelvic floor defects that are not always evident of physical examination. In this study, dynamic magnetic resonance imaging of symptomatic patients with pelvic floor prolapse demonstrated unsuspected levator ani hernia. This study was designed to identify any specific symptoms and/or physical findings associated with these hernias.METHODS: Eighty consecutive patients with pelvic organ prolapse, fecal and/or urinary incontinence, or chronic constipation received standardized questionnaires, physical examination, and dynamic magnetic resonance imaging. Fishers exact test was used to compare symptoms and examination findings between patients with or without levator ani hernia.RESULTS: Twelve patients (15 percent) were found to have unilateral (n = 8) or bilateral (n = 4) levator ani hernias on dynamic magnetic resonance imaging. No one specific symptom was directly associated with the presence of a levator ani hernia. Furthermore, levator ani hernias were not found more frequently in patients with previous pelvic floor surgery. Perineal descent on physical examination was associated with the finding of a levator ani hernia in nine patients (P = 0.02). Although not statistically significant, there was a trend toward a lower incidence of levator ani hernia in females using estrogen replacement therapy (P = 0.06).CONCLUSIONS: Patients with symptomatic pelvic organ prolapse and perineal descent on physical examination may have a levator ani hernia. Although the significance of levator ani hernia needs to be determined, the recurrence rate after the surgical management of pelvic organ prolapse remains unacceptably high, and ongoing investigation of all associated abnormalities is warranted.Data were obtained from the Johns Hopkins Pelvic Floor Database. Poster presentation at The American Society of Colon and Rectal Surgery Meeting, Boston, Massachusetts, June 24 to 29, 2000.     

Dynamic pelvic magnetic resonance imaging and cystocolpoproctography alter surgical management of pelvic floor disorders

PURPOSE: Pelvic organ prolapse results in a spectrum of progressively disabling disorders. Despite attempts to standardize the clinical examination, a variety of imaging techniques are used. The purpose of this study was to evaluate dynamic pelvic magnetic resonance imaging and dynamic cystocolpoproctography in the surgical management of females with complex pelvic floor disorders. METHODS: Twenty-two patients were identified from The Johns Hopkins Pelvic Floor Disorders Center database who had symptoms of complex pelvic organ prolapse and underwent dynamic magnetic resonance, dynamic cystocolpoproctography, and subsequent multidisciplinary review and operative repair. RESULTS: The mean age of the study group was 58 ± 13 years, and all patients were Caucasian. Constipation (95.5 percent), urinary incontinence (77.3 percent), complaints of incomplete fecal evacuation (59.1 percent), and bulging vaginal tissues (54.4 percent) were the most common complaints on presentation. All patients had multiple complaints with a median number of 4 symptoms (range, 2–8). Physical examination, dynamic magnetic resonance imaging, and dynamic cystocolpoproctography were concordant for rectocele, enterocele, cystocele, and perineal descent in only 41 percent of patients. Dynamic imaging lead to changes in the initial operative plan in 41 percent of patients. Dynamic magnetic resonance was the only modality that identified levator ani hernias. Dynamic cystocolpoproctography identified sigmoidoceles and internal rectal prolapse more often than physical examination or dynamic magnetic resonance. CONCLUSIONS: Levator ani hernias are often missed by physical examination and traditional fluoroscopic imaging. Dynamic magnetic resonance and cystocolpoproctography are complementary studies to the physical examination that may alter the surgical management of females with complex pelvic floor disorders.Presented at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 24 to 29, 2000.No reprints are available.     

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.Video presentation at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

Diagnosing enteroceles using dynamic magnetic resonance imaging

PURPOSE: Enteroceles are in part difficult to detect but a frequent finding in pelvic floor disorders. The aim of this study was to evaluate magnetic resonance colpocystorectography in the diagnosis of enteroceles. METHODS: In this prospective study 11 volunteers and 55 patients with pelvic floor descent were examined. In addition to magnetic resonance colpocystorectography, a dynamic cystoproctography was performed on 34 patients. Opacification of organs was used. An enterocele was assessed in relationship to the pubococcygeal reference line (magnetic resonance colpocystorectography) or the width of the rectovaginal space (dynamic cystoproctography). A clinical gynecologic examination served as reference. RESULTS: The clinical examination diagnosed an enterocele in 43, magnetic resonance colpocystorectography in 49, and dynamic cystoproctography in 14 cases. Magnetic resonance colpocystorectography further subdivided the enteroceles according to their contents (mesenteric fat or fluid, 12; small bowel, 32, large bowel, 3; and rectosigmoidocele, 2). Magnetic resonance colpocystorectography proved statistically significantly superior to dynamic cystoproctography (15 cases) and the reference. Sensitivity and specificity of magnetic resonance colpocystorectography were 100 percent each. It was able to reveal clinically missed enteroceles as being peritoneoceles associated with a rectocele or a uterovaginal prolapse (10 cases). CONCLUSION: Magnetic resonance colpocystorectography is a promising method for diagnosis of enteroceles, because hernial canal, sac, and contents are reliably identified.Presented at Radiology 1998, Birmingham, United Kingdom, June 1 to 3, 1998.     

Dynamic MR imaging of outlet obstruction

The outlet obstruction syndrome encompasses all pelvic floor abnormalities which are responsible for an incomplete evacuation of fecal contents from the rectum. It has been estimated that outlet obstruction may be observed in half of constipated patients. A detailed clinical examination still represents the cornerstone of the diagnosis of these patients. However, there is general agreement that a reliable evaluation of the different pelvic floor abnormalities and the treatment decision highly depend on the imaging assessment. Traditionally, conventional defecography has played an important role in the radiological assessment of these patients but the technique is limited by its projectional nature and its inability to detect soft-tissue structures. Dynamic pelvic MR imaging using either closed-configuration or open-configuration MR systems is a rapidly evolving technique which has been gaining increased interest over the last years. The free selection of imaging planes, the good temporal resolution, and the excellent soft-tissue contrast have transformed this method into the preferred imaging modality in the evaluation of patients with pelvic floor dysfunction including rectocele, enterocele, internal rectal prolapse, and anismus.     

Anatomy and nerve supply of the pelvic floor

In order to guarantee urinary and fecal continence as well as correct pelvic statics, the perfect neuroanatomical integrity of the pelvic floor muscles is mandatory. As Dickinson stated: "There is no considerable muscle in the body whose form and function are more difficult to understand than those of the levator ani, and about which such nebulous impressions prevail". Clinical implications of pelvic floor anatomy and nerve supply are evident: a denervation of this muscle group and the consequent muscle dysfunction could result in urinary and/or fecal incontinence, as well as pelvic organ prolapse.     

Pelvic organ prolapse: a review

Pelvic organ prolapse is a common medical problem in parous women. This condition usually refers to a combination of deficiencies of the pelvic organs as they relate to support mechanisms of the vaginal wall. Symptoms vary--an accurate diagnosis requires a careful and complete physical examination with attention directed toward the pelvis and perineum. Although many patients will not require surgical treatment for pelvic organ prolapse, a comprehensive approach to repair in which all of the anatomic defects affecting support are addressed is necessary for successful treatment. Patients presenting with pelvic organ prolapse often provide some of the most complex, challenging, and rewarding cases in reconstructive pelvic surgery. This article addresses the definitions and classifications, prevalence and risk factors, and anatomy and pathophysiology relevant to pelvic organ prolapse. Discussion also includes diagnosis and approaches to management (surgical and nonsurgical) of anterior vaginal wall prolapse, cystourethrocele, apical vaginal prolapse, uterine prolapse and enterocele, posterior vaginal wall prolapse, rectocele, and pelvic floor relaxation and perineal laxity, with indications for and approaches to surgery, along with possible complications.     

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.     

Evaluation of acupuncture treatments of postpartum female pelvic floor dysfunction by four-dimensional transperineal pelvic floor ultrasound

Introduction:In the present investigation, a systematic evaluation of the clinical treatment performance of diagnosed with pelvic floor dysfunction is explored. By comparing the 4Dtransperineal pelvic floor ultrasound images with the acupuncture treatment performance of the patients, an evaluation system with various parameters is established to provide critical information to guide the clinical treatment fpostpartum female pelvic floor dysfunction (FPFD).Methods:Eighty patients diagnosed with FPFD are divided into 2 groups. After the designated treatment to the patients, they are carefully examined using transperineal pelvic floor ultrasound. The shape and activity of bladder neck, cervix and rectum anal canal under resting, anal sphincter and Valsalva movements are observed and recorded. The morphology and continuous shape of levator ani muscle in different states after 4D image reconstruction are obtained.Results:After the acupuncture treatment, the bladder neck descent is decreased by 3.8 cm and the anal levator muscle area is decreased by 3.4 cm² comparing with the control group. The anal levator muscle hole diameter is decreased by 0.3 cm, while the anterior and posterior diameter is reduced by 0.5 cm. Reduced possibility of cystocele and uterine prolapse is demonstrated by X² test. These changes upon acupuncture therapy are in line with the improved conditions of the patients, indicating these parameters can help evaluate the therapy performance.Conclusion:4D pelvic floor ultrasound imaging provides objective and quantified information for the clinical diagnosis and treatment of FPFD and the assessment of therapy efficacy, making it a promising novel method in practical applications.     

盆腔器官脱垂的动态MRI研究进展

盆腔器官脱垂(pelvic organ prolapse,POP)是指由于盆底支持结构薄弱导致的盆腔器官疝出.动态MRI为无放射性、无创、快捷、全面、高分辨率的检查方法,其软组织对比性强,可清晰显示静息位及动态位时盆底肌肉和筋膜组织结构及功能上的变化,了解盆腔多组织器官的状况,为临床提供客观影像学数据.动态MRI常用于...     

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. Received: 10 April 2001 / Accepted: 21 May 2001     

Pelvic organ prolapse

Pelvic organ prolapse is downward descent of female pelvic organs, including the bladder, uterus or post-hysterectomy vaginal cuff, and the small or large bowel, resulting in protrusion of the vagina, uterus, or both. Prolapse development is multifactorial, with vaginal child birth, advancing age, and increasing body-mass index as the most consistent risk factors. Vaginal delivery, hysterectomy, chronic straining, normal ageing, and abnormalities of connective tissue or connective-tissue repair predispose some women to disruption, stretching, or dysfunction of the levator ani complex, connective-tissue attachments of the vagina, or both, resulting in prolapse. Patients generally present with several complaints, including bladder, bowel, and pelvic symptoms; however, with the exception of vaginal bulging, none is specific to prolapse. Women with symptoms suggestive of prolapse should undergo a pelvic examination and medical history check. Radiographic assessment is usually unnecessary. Many women with pelvic organ prolapse are asymptomatic and do not need treatment. When prolapse is symptomatic, options include observation, pessary use, and surgery. Surgical strategies for prolapse can be categorised broadly by reconstructive and obliterative techniques. Reconstructive procedures can be done by either an abdominal or vaginal approach. Although no effective prevention strategy for prolapse has been identified, considerations include weight loss, reduction of heavy lifting, treatment of constipation, modification or reduction of obstetric risk factors, and pelvic-floor physical therapy.     

阴道全封闭术治疗老年女性盆腔器官脱垂的疗效

目的 分析老年女性盆腔器官脱垂(POP)患者实施阴道全封闭术的临床疗效及安全性.方法 选取2012年1月至2018年1月在佛山市妇幼保健院妇科住院治疗、盆腔器官脱垂分期法(POP-Q)评定为Ⅲ～Ⅳ期、并接受阴道全封闭术治疗的78例老年POP患者.所有患者治疗后进行1年随访观察,记录术前和术后POP-Q分期情况.分析患者...     

Management of pelvic organ prolapse

Symptomatic pelvic organ prolapse can afflict up to 10% of women. Urinary incontinence, voiding dysfunction or difficulty possibly related to bladder outlet obstruction are common symptoms. Infrequently hydronephrosis or defecatory dysfunction can be seen. The management of pelvic organ prolapse (POP) should start with adequate assessment of all pelvic floor complaints. If a patient is not symptomatic, surgical intervention is usually not indicated. While the use of a variety of graft materials are available today including porcine, dermal and synthetic grafts, that are used in some surgical approaches to pelvic organ prolapse, other more conservative approaches may prove beneficial to many patients. This article describes our approach to the patient with pelvic organ prolapse.     

MR-defecography in obstructed defecation syndrome (ODS): technique, diagnostic criteria and grading

Background

The aim of this study was to evaluate the use of a magnetic resonance (MR)-based classification system of obstructive defecation syndrome (ODS) to guide physicians in patient management.

Methods

The medical records and imaging series of 105 consecutive patients (90 female, 15 male, aged 21–78 years, mean age 46.1 ± 5.1 years) referred to our center between April 2011 and January 2012 for symptoms of ODS were retrospectively examined. After history taking and a complete clinical examination, patients underwent MR imaging according to a standard protocol using a 0.35 T permanent field, horizontally oriented open-configuration magnet. Static and dynamic MR-defecography was performed using recognized parameters and well-established diagnostic criteria.

Results

Sixty-seven out of 105 (64 %) patients found the prone position more comfortable for the evacuation of rectal contrast while 10/105 (9.5 %) were unable to empty their rectum despite repeated attempts. Increased hiatus size, anterior rectocele and focal or extensive defects of the levator ani muscle were the most frequent abnormalities (67.6, 60.0 and 51.4 %, respectively). An MR-based classification was developed based on the combinations of abnormalities found: Grade 1 = functional abnormality, including paradoxical contraction of the puborectalis muscle, without anatomical defect affecting the musculo-fascial structures; Grade 2 = functional defect associated with a minor anatomical defect such as rectocele ≤2 cm in size and/or first-degree intussusception; Grade 3 = severe defects confined to the posterior anatomical compartment, including >2 cm rectocele, second- or higher-degree intussusception, full-thickness external rectal prolapse, poor mesorectal posterior fixation, rectal descent >5 cm, levator ani muscle rupture, ballooning of the levator hiatus and focal detachment of the endopelvic fascia; Grade 4 = combined defects of two or three pelvic floor compartments, including cystocele, hysterocele, enlarged urogenital hiatus, fascial tears enterocele or peritoneocele; Grade 5 = changes after failed surgical repair abscess/sinus tracts, rectal pockets, anastomotic strictures, small uncompliant rectum, kinking and/or lateral shift of supra-anastomotic portion and pudendal nerve entrapment.

Conclusions

According to our classification, Grades 1 and 2 may be amenable to conservative therapy; Grade 3 may require surgical intervention by a coloproctologist; Grade 4 would need a combined urogynecological and coloproctological approach; and Grade 5 may require an even more complex multidisciplinary approach. Validation studies are needed to assess whether this MR-based classification system leads to a better management of patients with ODS.     

Role of pelvicography and colpocystodefecography in diagnosis of outlet obstructive constipation

Aims The aim was to research the changes in pelvic floor morphology and corresponding visceras in patients with outlet obstructive constipation (OOC).Patients and methods Thirty-eight patients with OOC and 12 healthy volunteers were enrolled in this study. With simultaneous pelvicography and colpocystodefecography (PCCD), including pelvicography, vaginal opacification, voiding cystography and defecography, pelvic floor morphology was observed and the anorectal angle, the level of the perineum, peritoneum and bladder were measured.Results Thirty-seven cases of internal rectal prolapse (IRP), 5 cases of rectocele (RC) and 5 cases of spastic pelvic floor syndrome SPFS were diagnosed by PCCD. 12 IRP, 4 RC and 1 SPFS were detected by common physical examination. All of these were confirmed by PCCD. Moreover, PCCD found 9 pelvic floor hernia or peritoneoceles, 6 cystoceles, 3 descending perineum syndromes and 10 uterine prolapses. Compared with controls, OOC patients had a significantly large anorectal angle during defecation, abnormal descending of the perineum at rest and during defecation, and a deep pouch of Douglas during defecation. Some patients with urinary system symptoms may have had an abnormal descent of the bladder during rest and defecation.Conclusion Simultaneous PCCD has a higher positive ratio than the common physical examination in diagnosing IRP and RC, and provides information for the diagnosis of pelvic floor hernia or peritoneocele, cystocele or uterine prolapse. PCCD is helpful in the selection of a proper surgical procedure.     

Dynamic magnetic resonance defecography in 10 asymptomatic volunteers

AIM: Evaluation of the wide range of normal findings in asymptomatic women undergoing dynamic magnetic resonance (MR) defecography.METHODS: MR defecography of 10 healthy female volunteers (median age: 31 years) without previous pregnancies or history of surgery were evaluated. The rectum was filled with 180 mL gadolinium ultrasound gel mixture. MR defecography was performed in the supine position. The pelvic floor was visualized with a dynamic T2-weighted sagittal plane where all relevant pelvic floor organs were acquired during defecation. The volunteers were instructed to relax and then to perform straining maneuvers to empty the rectum. The pubococcygeal line (PCGL) was used as the line of reference. The movement of pelvic floor organs was measured as the vertical distance to this reference line. Data were recorded in the resting position as well as during the defecation process with maximal straining. Examinations were performed and evaluated by two experienced abdominal radiologists without knowledge of patient history.RESULTS: Average position of the anorectal junction was located at -5.3 mm at rest and -29.9 mm during straining. The anorectal angle widened significantly from 93° at rest to 109° during defecation. A rectocele was diagnosed in eight out of 10 volunteers showing an average diameter of 25.9 mm. The bladder base was located at a position of +23 mm at rest and descended to -8.1 mm during defecation in relation to the PCGL. The bladder base moved below the PCGL in six out of 10 volunteers, which was formally defined as a cystocele. The uterocervical junction was located at an average level of +43.1 mm at rest and at +7.9 mm during straining. The uterocervical junction of three volunteers fell below the PCGL; described formally as uterocervical prolapse.CONCLUSION: Based on the range of standard values in asymptomatic volunteers, MR defecography values for pathological changes have to be re-evaluated.     

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.

     

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     

Prevalence and severity of urinary incontinence and pelvic genital prolapse in females with anal incontinence or rectal prolapse

PURPOSE: The aim of this study was to determine the prevalence, severity, and associations between urinary incontinence and genital prolapse in females after surgery for fecal incontinence or rectal prolapse. METHODS: All patients who underwent surgery for fecal incontinence (Group I) or rectal prolapse (Group II) were compared with a control group of females (Group III) by 43 questions regarding demographic data, past medical and surgical history, and diagnosis and treatment of anal and urinary incontinence and genital and rectal prolapse. The type (stress, urge, and total) of urinary incontinence was determined and graded using an incontinence severity questionnaire (Individual Incontinence Impact Questionnaire). RESULTS: Overall response rate in the three groups of patients was 40.1 percent. The questionnaire was sent to 240 patients operated on for fecal incontinence or rectal prolapse, and 83 of them responded (34.5 percent). The patients were distributed into three groups: Group I consisted of 51 patients (mean age 56.7 +/- 14); Group II consisted of 32 patients (69.7 +/- 11); and Group III consisted of 40 patients (60.5 +/- 16). The prevalence of urinary incontinence in Group I was 27 (54 percent), in Group II was 21 (65.6 percent), and Group III was 12 patients (30 percent; P = 0.003). Genital prolapse was present in 9 (17.6 percent), 11 (34.3 percent), and 5 patients (12.5 percent), respectively (P = 0.03). The prevalence of coexistent urinary incontinence and genital prolapse in both study groups was 22.8 percent (19 patients). There were no statistically significant differences between Groups I and II relative to prevalence, type, and severity of urinary incontinence and genital prolapse, but there were significant differences between the two study groups and the control group. Of the patients in the study group, 67 percent had urinary incontinence before or at the time of surgery. CONCLUSION: There is a higher prevalence and severity of urinary incontinence and pelvic genital prolapse in females operated on for either fecal incontinence or rectal prolapse than in a control group. Therefore, female patients with fecal incontinence or rectal prolapse should be evaluated and treated by a multidisciplinary group of pelvic floor clinicians, including a gynecologist or urologist with special training in female pelvic floor dysfunction and a colorectal surgeon.