Dynamic MR defecography with an open-configuration, low-field, tilting MR system in patients with pelvic floor disorders

Purpose

This study was undertaken to explore the capabilities of an open-configuration, low-field, tilting, magnetic resonance (MR) system for investigating pelvic floor disorders and to compare the results obtained with the patient in the semiorthostatic and supine positions.

Materials and methods

Eighteen female patients with a diagnosis of pelvic floor disorder (physical examination and conventional defecography) underwent dynamic MR defecography (MRD) with a 0.25-T tilting MR system (G-scan, Esaote). Images were obtained after administration of contrast agent into the rectum, bladder and vagina in both the orthostatic and supine positions. Three-dimensional T2-weighted hybrid contrast-enhanced (HYCE) sequences and dynamic T1-weighted gradient echo (GE) sequences were acquired at rest, during maximal contraction of the anal sphincter, straining and defecation.

Results

Good image quality was obtained in 15/18 patients; three presented severe artefacts due to motion, and three had incontinence, which hampered the functional studies. Better anatomical detail was obtained with MRD compared with conventional defecography. Three prolapses were observed in the semiorthostatic position only, and seven were found to be more severe in the orthostatic than in the supine position.

Conclusions

Dynamic MRD with an open-configuration, low-field, tilting MR system is a feasible and promising tool for studying the pelvic floor. Larger series are necessary to assess its real diagnostic value.     

Anorectal function in patients with defecation disorders and asymptomatic subjects: evaluation with defecography

A controlled radiologic study of anorectal function was performed with the use of defecography in 19 patients with constipation and 13 with incontinence. All patients were age and sex matched to control subjects who were referred for barium enema study and who had no defecation disorder. There were no statistically significant differences between either patient group and the control group in anorectal angle and excursion of the anorectal junction. In the 32 patients and 155 consecutive patients referred for defecography because of a variety of defecation disturbances, approximately twice as many rectal wall abnormalities were seen compared with findings in the control group. These findings included intussusception, rectal prolapse, rectocele, mucosal prolapse, spastic pelvic floor, descending perineum syndrome, and solitary rectal ulcer syndrome. In conclusion, the main role of defecography is to document rectal wall changes during defecation straining as possible causes of evacuation difficulties. Clinical symptoms should also be taken into account when treatment is contemplated.     

MR排便造影在后盆腔障碍性疾病中的评估价值

后盆腔障碍疾病是以肛直肠解剖和功能异常为主的一类盆底功能障碍性疾病,伴有便秘、便失禁等临床症状。MR排便造影是一种动态MR成像方法,可对后盆腔结构形态和运动功能异常情况直观显示,能够鉴别后盆腔障碍性疾病的类型并认识其发病原因,如直肠膨出、肠疝、盆腔器官脱垂和直肠套叠、脱垂等,同时对便失禁早期的肛直肠形态学和功能学异常改变的诊断有重要提示价值。     

直肠内注入模拟粪便的动态MRI对女性盆底痉挛综合征的诊断价值

目的 利用动态MRI研究直肠内模拟粪便注入前、后女性盆底痉挛综合征(SPFS)患者的肛直肠形态、功能性病变, 并对多盆腔器官脱垂进行评价, 明确注入球囊后的动态MRI在SPFS患者中的诊断优势。 方法 对53例临床诊断为SPFS的女性患者行动态MRI检查, 使用自行设计高顺应性球囊模拟大便, 测量患者直肠内球囊注入前、后力排相盆底的相关数据。 结果 盆底动态MRI结果显示, 53例女性SPFS患者中, 伴发多盆腔器官脱垂者24例。直肠内造影剂注入前、后力排相的肛直角变化, 差异无统计学意义(χ2=0.603, P > 0.05);相比直肠内模拟粪便注入后的盆底动态MRI, 未注入的力排相分别有18.0%(9/50)膀胱脱垂、6.1%(3/49)子宫或阴道穹窿脱垂、32.7%(17/52)直肠前膨出及14.6%(7/48)会阴体下降诊断为阴性。直肠内模拟粪便注入前、后力排相观察多盆腔器官脱垂变化, 差异均有明显统计学意义。 结论 直肠内注入模拟粪便的盆底动态MRI为女性SPFS患者提供了更全面的诊断, 为术前正确诊断盆腔多部位缺陷及术后正确评价治疗效果提供了客观依据。     

Dynamic MR imaging of the pelvic floor performed with patient sitting in an open-magnet unit versus with patient supine in a closed-magnet unit

PURPOSE: To compare open-magnet magnetic resonance (MR) imaging performed with the patient sitting with dynamic closed-magnet MR imaging of the pelvic floor performed with the patient supine. MATERIALS AND METHODS: Thirty-eight patients underwent dynamic 1.5-T closed-magnet pelvic floor MR imaging while in the supine position. Midsagittal T2-weighted single-shot fast spin-echo and T1-weighted multiphase spoiled gradient-recalled-echo (SPGR) MR images were obtained before and after rectal contrast agent administration, respectively, with the patient at rest, straining, and maximally contracting the sphincter. Subsequently, the patient was transferred to an open 0.5-T system. Midsagittal multiphase T1-weighted SPGR MR images were then obtained every 2 seconds with the patient sitting while at rest, maximally contracting the sphincter, straining, and defecating. Images were analyzed with regard to presence of enteroceles, anterior rectoceles, intussusceptions, rectal descents, bladder descents, and vaginal vault descents. RESULTS: All intussusceptions were missed at supine MR imaging. With sitting MR imaging as the reference standard, the sensitivity of supine MR imaging was 79% for depiction of bladder descents. When MR findings were graded and clinically irrelevant MR findings were excluded, sensitivity increased to 100% for depiction of bladder descents and anterior rectoceles and to 96% for depiction of rectal descents. CONCLUSION: Dynamic supine MR imaging performed with a closed-configuration unit before and after rectal contrast agent administration appears to be an alternative to sitting MR defecography performed with an open-configuration unit for diagnosis of clinically relevant pelvic floor abnormalities.     

排粪X线造影在肠易激综合征诊断中的应用

为了解排粪X线造影在肠易激综合征患者中的应用价值，对12例便秘为主型、10例便秘和腹泻交替型、14例腹泻型肠易激综合征患者进行排粪X线造影。结果排粪造影阳性的例数为13例（36.11％），排便过程中的异常有多种，包括直肠前突、直肠粘膜脱垂、内脏下垂、会阴下降和盆底痉挛综合征等。说明排粪X线造影对肠易激综合征的诊断和治疗有一定的价值。     

MR defecography in patients with fecal incontinence: imaging findings and their effect on surgical management

PURPOSE: To retrospectively evaluate magnetic resonance (MR) defecography findings in patients with fecal incontinence who were evaluated for surgical treatment and to assess the influence of MR defecography on surgical therapy. MATERIALS AND METHODS: Institutional review board approval was obtained. Informed consent was waived; however, written informed consent for imaging was obtained. Fifty patients (44 women, six men; mean age, 61 years) with fecal incontinence were placed in a sitting position and underwent MR defecography performed with an open-configuration MR system. Midsagittal T1-weighted MR images were obtained at rest, at maximal contraction of the sphincter, and at defecation. Images were prospectively and retrospectively reviewed by two independent observers for a variety of findings. Interobserver agreement was analyzed by calculating kappa statistics. Prospective interpretation of MR defecography findings was used to influence surgical therapy, and retrospective interpretation was used for concomitant pelvic floor disorders. RESULTS: MR defecography revealed rectal descent of more than 6 cm (relative to the pubococcygeal line) in 47 (94%) of 50 patients. A bladder descent of more than 3 cm was present in 20 (40%) of 50 patients, and a vaginal vault descent of more than 3 cm was present in 19 (43%) of 44 women. Moreover, 17 (34%) anterior proctoceles, 16 (32%) enteroceles, and 10 (20%) rectal prolapses were noted. Interobserver agreement was good to excellent (kappa = 0.6-0.91) for image analysis results. MR defecography findings led to changes in the surgical approach in 22 (67%) of 33 patients who underwent surgery. CONCLUSION: MR defecography may demonstrate a variety of abnormal findings in patients who are considered candidates for surgical therapy for fecal incontinence, and the findings may influence the surgical treatment that is subsequently chosen. Supplemental material: http://radiology.rsnajnls.org/cgi/content/full/2402050648/DC1     

MR排粪造影在女性出口梗阻型便秘研究中的应用价值

目的 利用MR排粪造影研究女性出口梗阻型便秘的肛、直肠形态及功能性病变,同时对前、中盆腔联合性病变进行全面评价.方法 107例临床诊断为出口梗阻型便秘的女性患者,年龄20～84岁,平均55岁,进行MR排粪造影检查,使用自行设计高顺应性球囊模拟大便,分别测量静息、提肛及力排时盆底相关数据.结果 107例出口梗阻型便秘患者中,70例直肠前膨出(65.4%),为女性出口型便秘常见梗阻因素;85例(79.4%)患者为2种及2种以上的联合性病变,并发前、中盆腔病变,包括60例膀胱脱垂(56.1%)、59例子宫或阴道穹窿脱垂(55.1%)、54例会阴体下降(50.5%)、28例盆底疝(26.2%).结论 MR排粪造影不仅能准确评价出口梗阻型便秘女性患者的肛、直肠形态及功能性病变,同时能对前、中盆腔联合性病变进行全面评价.     

Integrated study of fecal incontinence with defecography, anal ultrasonography, perineography, and manometry

INTRODUCTION: Imaging methods such as defecography, anal US and perineography, combined with manometry, now permit to identify a growing number of causes of anorectal and pelvic floor deficiency. Fecal incontinence patients can thus be approached correctly relative to both diagnosis and treatment. We investigated the role of these techniques in the work-up of fecal incontinence. MATERIAL AND METHODS: Thirty-eight subjects suffering from fecal incontinence were examined. Defecography was carried out with a special commode and videorecorded on a VHS cassette. Anal US was performed with a 7-MHz rotating probe (type 1846) with 3-cm focus length. Perineography was carried out in 15 female patients. RESULTS: The anorectal angle (ARA) at rest was increased (mean: 106 degrees; normal range: 90-100 degrees) in 34 cases; involuntary barium leakage was seen in 8 patients, especially on coughing. On squeezing, ARA was normal in 10 cases (mean: 72 degrees; normal range: 60-90 degrees); in 5 cases of puborectal hypotonia there was no angular excursion between rest and squeezing (mean: 105 degrees). During evacuation, the average ARA value was 166 degrees in 21 cases and ARA stretched to verticalization in 8 cases (mean: 179 degrees). Morphofunctional anorectal changes appeared as rectal mucosal prolapse (12 cases), rectocele (10 cases), perineal descent syndrome (8 cases) and external rectal prolapse (3 cases). Anal US identified 15 interruptions in sphincterial rings: 12 patterns were hypoechoic, 2 mixed and 1 hyperechoic. Atrophic thinning of internal anal sphincter was seen in 5 idiopathic incontinence patients. Perineography demonstrated cystocele in 5 cases and cystourethrocele in 1 case. Manometry showed sphincterial hypotonia at rest in 15 cases, lower values of anorectal pressure on squeezing in 8 and smaller air volumes inhibiting external sphincterial tone in 19 cases. CONCLUSIONS: Defecographic studies with evaluation of ARA and its changes are an important tool with high diagnostic yield. When combined with other techniques, they provide differential criteria for sphincterial and puborectal causes and permits to identify associated pelvic floor dysfunctions. We believe that defecography, anal US (and perineography in complex disorders) are necessary techniques for the correct clinical approach to fecal incontinence patients, whose role and diagnostic yield are a valid support to manometry.     

Functional imaging of the pelvic floor

The clinical treatment of patients with anorectal and pelvic floor dysfunction is often difficult. Dynamic cystocolpoproctography (DCP) has evolved from a method of evaluating the anorectum for functional disorders to its current status as a functional method of evaluating the global pelvic floor for defecatory disorders and pelvic organ prolapse. It has both high observer accuracy and a high yield of positive diagnoses. Clinicians find it a useful diagnostic tool that can alter management decisions from surgical to medical and vice versa in many cases. Functional radiography provides the maximum stress to the pelvic floor, resulting in levator ani relaxation accompanied by rectal emptying-which is needed to diagnose defecatory disorders. It also provides organ-specific quantificative information about female pelvic organ prolapse-information that usually can only be inferred by means of physical examination. The application of functional radiography to the assessment of defecatory disorders and pelvic organ prolapse has highlighted the limitations of physical examination. It has become clear that pelvic floor disorders rarely occur in isolation and that global pelvic floor assessment is necessary. Despite the advances in other imaging methods, DCP has remained a practical, cost-effective procedure for the evaluation of anorectal and pelvic floor dysfunction. In this article, the authors describe the technique they use when performing DCP, define the radiographic criteria used for diagnosis, and discuss the limitations and clinical utility of DCP.     

Defecography and treatment of essential anal pain

INTRODUCTION: Proctalgia is a chronic anal pain in the absence of any organic conditions of the anorectum and excluding such morphofunctional disorders as rectal prolapse, intussusception and solitary rectal ulcer, which are easily shown with defecography but not with other imaging techniques. Proctalgia patients undergo a long workup and many instrumental and radiologic examinations and are finally referred to the proctologist with a condition which is difficult to diagnose and treat. We investigated the defecographic findings and anorectal abnormalities of essential proctalgia, as well as the correlation between radiologic findings, clinical symptoms and efficacy of biofeedback treatment. MATERIALS AND METHODS: We retrospectively examined 31 patients (21 women and 10 men; age range: 25-67 years, mean: 46) with defecography, clinico-proctologic investigations integrated with anoscopy and sigmoidoscopy, anorectal manometry and psychological tests. The women were submitted to gynecologic examination: 8 patients had a history of anorectal and pelvic surgery. We did not perform anal electromyography because it may cause painful sphincterial spasms. All patients underwent 30-minute weekly sessions of biofeedback till regression of symptoms. RESULTS: Anal pain was described as anorectal in 18 cases, anoperineal in 7, anosphincterial in 5 and rectovaginal in 1 case. It radiated to the sacrum in 42% of cases, thighs in 23%, gluteus muscles in 19%, and was related to evacuation in 39% of cases. Pain lasted some hours (58%) to a few minutes (42%). Manometric data showed sphincterial hypertonia in 14 patients. Eleven patients suffered from anxiety and were on drug treatment. Defecography demonstrated rectocele in 15 cases, puborectalis muscle syndrome in 14, external sphincter spasm in 12, perineal descent in 8, rectal muscosal prolapse in 4, intussusception in 3 and fecal incontinence in 2 cases. After 10 weeks of biofeedback training, all patients reported improvement of symptoms, which was confirmed at manometry as reduced sphincterial pressure. CONCLUSIONS: The etiology of essential proctalgia is unknown, but functional disorders of the pelvic floor and sphincterial muscles, as well as altered perineal stasis and pudendal conditions, all play an important role. These data are confirmed in our study where puborectalis syndrome, external sphincterial spasm and perineal descent are involved in over 70% of cases. Defecography is a useful tool because it permits to diagnose abnormal anorectal morphology and to diagnose sphincterial and puborectalis muscle dysfunctions which are missed with other instrumental and imaging techniques.     

Defecography by spiral computed tomography

PURPOSE: We investigated the possible role of helical CT defecography in pelvic floor disorders by comparing our results with those of conventional defecography. MATERIAL AND METHODS: Our series consisted of 90 patients, namely 62 women and 28 men, ranging in age 24-82 years. They were all submitted to conventional defecography, and 18 questionable cases were also studied with helical CT defecography. The conventional examination was performed during the 4 standard phases of resting, squeezing, Valsalva and straining; we used a remote-control unit. The parameters for helical CT defecography were: 5 mm beam collimation, pitch 2, 120 KV, 250 mAs and 18-20 degrees gantry inclination to acquire coronal images of the pelvic floor. The rectal ampulla was distended with a bolus of 300 mL nonionic iodinated contrast agent (dilution: 3 g/cc). The patient wore a napkin and was seated on the table, except for those who could not hold the position and were thus examined supine. Twenty-second helical scans were performed at rest and during evacuation; multiplanar reconstructions were obtained especially on the sagittal plane for comparison with conventional defecographic images. RESULTS: An unquestionable diagnosis could be made in all the 18 patients submitted to helical CT defecography. The diagnosis was in agreement with proctology results and added new information in all cases. Sixteen patients had constipation and 2 fecal incontinence--one from rectal prolapse and the other from a rectovaginal fistula. In this latter case helical CT defecography permitted to confirm the fistula and suggest its course. One patient had a previously undetected ovarian cancer metastatic to the anterior rectal wall. DISCUSSION AND CONCLUSIONS: Coronal helical CT defecography images permitted to map the perineal floor muscles, while sagittal reconstructions provided information on the ampulla and the levator ani. To conclude, helical CT defecography performed well in the study of pelvic floor disorders and can follow conventional defecography especially in questionable cases.     

Normal anorectum: dynamic MR imaging anatomy

In this study, the anatomy of the anorectum in relation to the surrounding structures and the anorectal angle were analyzed with magnetic resonance (MR) imaging at rest, during perineal contraction, and during straining in 10 asymptomatic subjects. The intra- and inter-observer and intra- and interpatient variations in the measurements of the anorectal angle, position of the anorectal junction, and position of the plica of Kohlrausch in the rectum were established at rest, during perineal contraction, and during straining. The values for the anorectal angle and position of the anorectal junction obtained with MR imaging were compared with standard radiography defecography findings. It was shown that MR imaging has the potential for measuring these parameters in a more precise and more patient-friendly way than defecography. Unlike dynamic defecography, MR imaging is able to depict the mobility of the posterior rectal wall. A descent of over 20 mm from rest to straining should be considered pathologic. This finding might play a role in patient selection for operation.     

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.     

盆底功能性疾病的动态MRI研究

目的　评价盆底动态MRI形态学表现与盆底功能性疾病的相关性。资料与方法　采用Siemens 1.0T超导磁共振成像仪对 6 0例妇女进行MRI检查 ,将这些受试者分为两组 :30例为无症状健康志愿者和 30例为盆底功能性疾病患者。采用仰卧位使用梯度回波二维FLASHT1WI快速扫描序列获得屏气期间盆底横断面、冠状面和矢状面的静息和最大盆腔用力时MR影像。所有影像用于观测盆腔器官脱垂和盆底形态 ,比较两组间盆腔器官脱垂和盆底形态变化的程度。结果　盆腔器官脱垂常发生于多个部位 ,盆底功能性疾病患者发生频率较高 ,与健康受试者比较相差显著 :膀胱膨出 (P <0 .0 1) ,子宫颈脱垂 (P <0 .0 1) ,盆底疝 (P <0 .0 1) ,直肠连接异常下降 (P <0 .0 1) ,直肠膨出 (P <0 .0 1)和盆隔裂孔膨胀 (P <0 .0 1)。结论　盆底动态MRI可用于准确评价盆腔器官脱垂和盆底形态 ,盆底功能性疾病患者常出现整个盆底软弱 ,盆腔器官脱垂频繁发生于多个部位并伴随盆隔裂孔的显著膨胀     

MR defecography in patients with dyssynergic defecation: spectrum of imaging findings and diagnostic value

Objectives

We describe the spectrum of findings and the diagnostic value of MR defecography in patients referred with suspicion of dyssynergic defecation.

Methods

48 patients (34 females, 14 males; mean age 48 years) with constipation and clinically suspected dyssynergic defecation underwent MR defecography. Patients were divided into patients with dyssynergic defecation (n = 18) and constipated patients without dyssynergic defecation (control group, n = 30). MRIs were analysed for evacuation ability, time to initiate evacuation, time of evacuation, changes in the anorectal angle (ARA-change), presence of paradoxical sphincter contraction and presence of additional pelvic floor abnormalities. Sensitivity, specificity, positive and negative predictive values and accuracy for the diagnosis of dyssynergic defecation were calculated.

Results

The most frequent finding was impaired evacuation, which was seen in 100% of patients with dyssynergic defecation and in 83% of the control group, yielding a sensitivity for MR defecography for the diagnosis of dyssynergic defecation of 100% (95% confidence interval (CI) 97–100%), but a specificity of only 23% (95% CI 7–40%). A lower sensitivity (50%; 95% CI 24–76%) and a high specificity (97%; 95% CI 89–100%) were seen with abnormal ARA-change. The sensitivity of paradoxical sphincter contraction was relatively high (83%; 95% CI 63–100%). A combined analysis of abnormal ARA-change and paradoxical sphincter contraction allowed for the detection of 94% (95% CI 81–100%) of the patients with dyssynergic defecation.

Conclusion

MR defecography detects functional and structural abnormal findings in patients with clinically suspected dyssynergic defecation. Impaired evacuation is seen in patients with functional constipation owing to other pelvic floor abnormalities than dyssynergic defecation.Dyssynergic defecation, which produces functional outlet obstruction during defecation, is one of the causes of chronic constipation. Dyssynergic defecation is a functional disorder characterised by either paradoxical contraction, an inability to relax the anal sphincter and/or puborectalis muscle, or impaired abdominal and rectal pushing forces. In the literature, many other terms such as anismus [1], dyskinetic puborectalis muscle [2], non-relaxing puborectalis syndrome [3], spastic pelvic floor syndrome [4, 5] and pelvic floor dyssynergia [6] have been used. An expert group (Rome III) [7] recently proposed the term “dyssynergic defecation” to appropriately describe the failure of co-ordination or dyssynergia of the abdominal and pelvic floor muscles involved in defecation. Different physiological tests can be used to investigate this functional disorder, including the balloon expulsion test, electromyography (EMG) of the puborectalis muscle and anorectal manometry. Defecography can be performed to rule out structural rectal abnormalities and provide an estimate of the degree of rectal emptying. As false-positive and false-negative results are common with these different tests, none can be used by itself as a gold standard for identifying patients with dyssynergic defecation.Most authorities recommend using a combination of diagnostic tests and clinical history. The Rome III expert group defined the criteria for the diagnosis of dyssynergic defecation based on clinical history, anorectal manometry, balloon expulsion test, EMG and conventional defecography (evacuation proctography) [7]. Functional imaging with conventional defecography is considered to be a useful adjunct in establishing the diagnosis of dyssynergic defecation. Delayed initiation of evacuation and impaired evacuation in particular, as seen on conventional defecography, are highly predicitive for the presence of dyssynergic defecation [8, 9]. Different structural imaging findings in conventional defecography have been described in patients with dyssynergic defecation; however, the usefulness of these findings is discussed controversially [8, 10, 11].The experience with MR defecography, which has shown to be a valuable alternative to evacuation proctography [12–15], is limited in dyssynergic defecation patients. There is only one study which has focused on the MR defecography findings in a study setting in patients with dyssynergic defecation [16]. Hence, the purpose of this study was to describe the spectrum of findings in MR defecography in patients referred with the suspicion of dyssynergic defecation and to assess the value of MR defecography in establishing this diagnosis. For the latter, the patients with dyssynergic defecation were compared with a group of constipated patients without dyssynergic defecation.     

Defecography used as a screening entry for identifying evacuatory pelvic floor disorders in childhood constipation

Defecography is one of the most valuable methods for the evaluation of pelvic floor disorders. Interest in this technique has rapidly expanded owing to its increased understanding of the multifactorial pathophysiology involving evacuation disorders. The value of defecography has reached a consensus in adulthood but is still limited in childhood. In this study, defecography was carried out in 8 volunteers and 96 constipation children. The results revealed that defecography can help to identify evacuatory pelvic floor disorders in childhood constipation. It is safe and feasible and should be used as a screening method for childhood constipation.     

The solitary rectal ulcer syndrome: diagnosis with defecography

The solitary rectal ulcer syndrome is an uncommon entity consisting of a rectal abnormality caused by straining during defecation and characterized by specific histologic changes. Endoscopy may show single or multiple ulcers or a preulcerative phase consisting of mucosal thickening. Findings on barium enema may be normal or nonspecific, consisting of a thickened valve of Houston, nodularity, and rectal stricture. Pathologic changes consist of replacement of the lamina propria by fibroblasts and smooth muscle fibers with marked hypertrophy of the muscularis mucosae. In five patients with histologically proved solitary rectal ulcer syndrome, defecography was performed to evaluate the accompanying defecation disorder. Two patients showed the spastic pelvic floor syndrome, characterized by failure of relaxation of the pelvic floor musculature during straining. In the remaining three, defecography showed an infolding of the rectal wall toward the rectal lumen increasing gradually to form an intussusception. The results indicate that defecography is useful to show the underlying disorder of defecation in the solitary rectal ulcer syndrome.     

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.