Association between rectocele and paradoxical sphincter response

Rectocele as well as paradoxical sphincter reaction may lead to rectal emptying difficulties and outlet obstruction. Forty-one patients with emptying disturbances and rectocele were investigated with defecography, anorectal manometry, colon transit time, and electromyography. Twenty-nine patients (71 percent) had concomitant paradoxical sphincter reaction, and 13 of these also had increased colon transit time. The functional results after surgical treatment of rectocele are not always satisfactory, probably because patients often have several causes for their emptying disturbances. It is emphasized that careful preoperative investigations are important before surgical treatment of rectocele in patients with emptying difficulties.Presented in part at the World Congress of Gastroenterology, Sydney, 1990 and the European Congress of Clinical Neurophysiology, Paris, 1990.     

Is paradoxical sphincter reaction provoked by needle electrode electromyography?

In 10 patients with emptying disturbances, the anal sphincter reaction was investigated clinically and by electromyography with needle and wire electrodes to elucidate whether pain during the investigation could provoke the paradoxical sphincter reaction. In eight of the patients, the paradoxical reaction was easily felt at digital examination. Two patients complained of pain during the needle electrode recording; none complained during the wire electrode investigation. Nevertheless, all 10 patients had paradoxical sphincter reaction independent of the electrode used at electromyography. With careful clinical investigation, most cases of paradoxical sphincter reaction can be diagnosed. When this is inconclusive, the diagnosis should be confirmed by electromyography, preferably by the wire technique.     

A new probe for measuring electromyographic activity from multiple sites in the anal canal

A new multiple electrode probe (MEP) designed to measure surface electromyographic activity from the subcutaneous and deep portions of the external anal sphincter is described. Using the MEP, electromyographic activity was sampled in an asymptomatic subject and in three incontinent patients. Comparisons of electromyographic data between and within subjects, and across sessions, indicate that the MEP discriminates muscle activity from different sites along the anal canal. The recording method described is capable of identifying patterns of muscle recruitment which have not been reported before using surface electromyography. After a defecation maneuver, the distal and proximal portions of external and sphincter were observed to contract in what would seem to be a closing reflex. Moreover, the absence of this pattern may indicate abnormality. Accordingly, the MEP promises to be useful in the diagnosis, evaluation, and treatment of fecal and urinary incontinence and, particularly, in the biofeedback treatment of these and related disorders.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.     

Paradoxical sphincter reaction is influenced by rectal filling volume

PURPOSE: Paradoxical sphincter reaction is frequently found in constipated patients but sometimes also in incontinent patients and in asymptomatic subjects. Its significance in defecation disorders has, therefore, been debated. The aim of the present study was to investigate whether paradoxical sphincter reaction is influenced by rectal filling volume. PATIENTS AND METHODS: Eighteen patients with defecation disorders and paradoxical sphincter reaction shown by electromyography were reinvestigated with an extended electromyographic investigation while in the lying position and while in the sitting position, with 50-ml, 100-ml, and 150-ml water-filled rectal balloons. RESULTS: All 18 patients showing paradoxical sphincter reaction in the first investigation also showed the reaction at the second investigation in the lying position with a 0-ml volume of rectal contents. In the sitting position, with a volume of 150 ml of rectal contents, the increase in electromyographic activity disappeared in seven patients (39 percent) and no longer showed paradoxical sphincter reaction. Electromyography showed decreased activity in one patient and unchanged activity in six patients during straining. A closing reflex was seen after completed straining in all of these seven patients. CONCLUSIONS: The present study demonstrates that paradoxical sphincter reaction diagnosed by electromyography is influenced by the rectal filling volume and might diminish when the rectum is filled with contents. The conventional electrophysiologic technique in the diagnosis of paradoxical sphincter reaction might, therefore, overdiagnose this condition.     

Behavioral medicine treatment in chronic constipation with paradoxical anal sphincter contraction

Nine women and five children with severe chronic constipation received behavioral medicine therapy. Before treatment, all patients had a paradoxical contraction of the external anal sphincter at defecation attempts as demonstrated with electromyography and/or anorectal manometry. An electromyographic biofeedback device connected to an anal probe was used for the training that was performed on a regular toilet seat during five 1-hour sessions. Thirteen of the patients improved considerably and could learn to defecate spontaneously, and the use of laxatives ceased or diminished. Simultaneously with improvement, the paradoxical anal contraction disappeared. The results remained after 6 months, although two of the patients had received booster sessions of biofeedback training during follow-up.This study was supported financially by the Örebro County Research Committee.     

Dynamic anal manometry in the assessment of patients with obstructed defecation

Patients with obstructed defecation show no consistent abnormalities when assessed by standard anorectal physiologic methods. With a recently developed technique for dynamic anal manometry, we studied 13 female patients with obstructed defecation and 20 healthy volunteers. Seven parameters of anal function were measured. There were no differences between the median values for the two groups. Seven patients (54 percent; 95 percent confidence limits, 25–81 percent) had anal compliance below the normal range, either during opening or closing of the sphincter at rest (five patients), during squeeze (one patient), or both (one patient). Opening and closing pressures of the sphincer at rest, maximal closing pressure during squeeze, and anal hysteresis were normal. Standard anal manometry did not show any differences between patients and controls. Rectal compliance was lower in patients with obstructed defecation, median difference 5 ml/cm H ₂ O (95 percent confidence limits, 1–9 ml/cm H ₂ O). In conclusion, the more detailed method of dynamic anal manometry shows that some patients with obstructed defecation have a less compliant anal sphincter and a less compliant rectum, but in many patients no abnormal findings can be made.     

Paradoxical puborectalis contraction in patients after pelvic pouch construction

Normal defecation is associated with relaxation of sphincters during the evacuation process. However, obstructive defecation is sometimes seen clinically manifested by abnormal contraction of the puborectalis during defecation rather than relaxing. This condition has not previously been described after pelvic pouch construction. PURPOSE: This study was done to evaluate patients for defecation difficulties caused by paradoxical puborectalis contraction after pelvic pouch procedures. METHODS: Prospectively, patients with defecation difficulties were questioned. They then underwent electromyography if they met particular criteria. Biofeedback was offered to all patients demonstrating paradox on electromyography. Follow-up was by clinic visits and interviews. RESULTS: After pelvic pouch construction, 13 patients were found to have paradoxical puborectalis contraction. Twelve of 13 patients elected to have biofeedback therapy. Eleven of these 12 were available for follow-up an average of eight (1–15) months after biofeedback. Nine improved, and two had no change in their defecation difficulty. Of the initial 13, 10 had an event, either pouchitis or abdominal trauma, directly before their defecation problems. CONCLUSION: Paradoxical puborectalis contraction can occur in patients after pelvic pouch surgery. It should be suspected in patients with defecation difficulties in the absence of an anatomic abnormality. Biofeedback is effective treatment.Read at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Defecography in patients with anorectal disorders

To evaluate the results and clinical impact of defecography in patients with anorectal disorders, 100 results of defecographic examinations from 92 patients were reviewed. The defecographic results were screened for the anorectal angle, defined both at rest and during straining, perineal descent, and abnormalities of the rectal configuration during straining. Anal manometry, saline infusion test, rectal capacity measurement, and anal electromyography (EMG) were also performed. There was a significant difference (P<0.001) both at rest (22°) and during straining (12°) between the two anorectal angle measurements. Incontinent patients had a larger anorectal angle, both at rest and during straining, than continent patients (P<0.04), but with a large overlap. The anorectal angle was not influenced by gender or age. An abnormal rectal configuration was found in 62 defecographic examinations. From the 8 patients with rectopexy performed for a large rectocele or intussusception, incontinent patients with an intussusception had the best results. In four patients, anal EMG showed an increased activity of the external sphincter during straining. Two of these four patients had abnormal defecograhic results. No correlations were found between anorectal angle and the other function tests. In conclusion, the anorectal angle lacks clinical relevance. In patients with defecation problems, defecography may be indicated whenever other investigations (physical examination, anal manometry, anal EMG) have excluded local pathology or a spastic pelvic floor syndrome. In these situations, defecography could detect an intussusception, which could easily be treated with rectopexy.Read in part at the meeting of the Dutch Society of Gastroenterology, Noordwijkerhout (The Netherlands), March 25 to 26, 1988.     

Simultaneous defecography and peritoneography in defecation disorders

A number of physiologic and radiologic investigations are used in investigating defecation disorders. Defecography is one important part of these investigations. However, a correct diagnosis of an enterocele is sometimes difficult despite use of contrast media in the rectum, vagina, and small bowel. PURPOSE: This study was undertaken to ascertain if it was technically possible to perform simultaneous defecography and peritoneography in an effort to improve the diagnostic possibilities in patients with defecation disorders. METHODS: Twelve patients with defecation disorders and an unexplained widening of the rectovaginal space at defecography were investigated. Contrast medium was introduced intraperitoneally, after which conventional defecography was performed. RESULTS: All investigations were carried out without complications and demonstrated the peritoneal outline in all patients. Simultaneous defecography and peritoneography differentiated between an enterocele and a pathologically deep pouch of Douglas—a peritoneocele. Three types of peritoneocele were visualized: vaginal peritoneocele, septal peritoneocele, and rectal peritoneocele with or without enterocele. Combinations of the three types were also found. Eight of the 12 patients had rectal intussusception or rectal prolapse. All of these eight patients had a rectal peritoneocele. CONCLUSIONS: Simultaneous defecography and peritoneography can be performed without technical difficulties or complications. Peritoneal outlines and pouches can, therefore, be studied directly during the act of defecation. An unexplained widening of the rectovaginal space at defecography can be clarified as a peritoneocele, with or without an enterocele. Peritoneocele can be of three different types: rectal, septal, or vaginal.Supported by grants from Marianne and Marcus Wallenbergs Stiftelse, Kjell and Märta Beijers Stiftelse, and Karolinska Institutet's research funds.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Paradoxical sphincter reaction and associated colorectal disorders

Of 71 patients with paradoxical sphincter reaction, 54 had symptoms of constipation or outlet obstruction and 17 were incontinent. The patients were investigated with defecography, colon transit time, anorectal manometry and electromyography. Ninety-six percent of the patients had additional changes in anorectal anatomy and physiology; 70% of the patients had abnormal defecography and 42% had delayed colon transit time. Decreased maximal anal pressure (MAP) and maximal squeeze pressure (MSP), indicating impaired function of the anal sphincters might be one reason for incontinence in patients with paradoxical sphincter reaction. The paradoxical reaction occurred in the puborectalis muscle and in three tested sites in the external sphincter. It is sufficient to record the EMG activity in one muscle and at one point to diagnose a paradoxical sphincter reaction. The absence of a normal closing reflex on electromyography is evidence for a paradoxical sphincter reaction. Denervation was more pronounced in the external sphincter than in the puborectalis muscle. The right pudendal nerve was subjected to damage more often than the left nerve.

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Résumé Parmi 71 patients présentant une réaction paradoxale du sphincter anal, 54 présentaient une constipation ou une dyschésie et 17 étaient incontinents. Ces patients avaient eu une défécographie, un temps de transit colique, une manométrie ano-rectale et une électromyographie. 96% d'entre eux présentaient des perturbations additionnelles de l'anatomie et de la physiologie ano-rectales. 70% de ces patients avaient une défécographie anormale et 42% un temps de transit colique prolongé. Une diminution de la pression anale maximale et de la pression de retenue maximale, indiquant une perturbation de la fonction des sphincters anaux, pourraient être une raison de l'incontinence de ces patients avec réaction paradoxale du sphincter. Cette réaction paradoxale survenait dans le muscle pubo-rectal et dans trois sites examinés du sphincter externe. Il est donc suffisant d'enregistrer l'électromyogramme dans un seul muscle et en un seul point pour diagnostiquer une réaction paradoxale du sphincter. L'absence d'un réflexe normal de fermeture en électromyographie témoigne d'une réaction paradoxale du sphincter. La dénervation était plus prononcée au niveau du sphincter externe que dans le muscle pubo-rectal. Le nerf honteux interne droit était plus souvent atteint que le nerf gauche.

     

Outpatient protocol for biofeedback therapy of pelvic floor outlet obstruction

Pelvic floor outlet obstruction is a rare cause of severe constipation. Anal myectomy, subtotal colectomy, and medical therapy have limited success. The purpose of this study was to develop a short outpatient treatment using biofeedback techniques. Nine patients with severe constipation and straining resulting from pelvic floor outlet obstruction underwent complete investigation of the pelvic floor musculature and anal sphincter mechanism. Patients were unable to expel a 60-cc rectal balloon and had nonrelaxing puborectalis on defecography. The treatment protocol utilized anal surface electromyography to document improper straining and retrain pelvic floor muscles to relax during defecation. Sensory retraining with a rectal balloon, behavioral relaxation techniques, and defecation of simulated stool using a 120-cc Metamucil^® (Procter & Gamble, Cincinnati, OH) slurry in the rectum allowed re-establishment of normal defecation in all nine patients. Repeat training was required in three patients during follow-up. Treatment of pelvic floor outlet obstruction with outpatient retraining techniques is possible.Read at the meeting of The American College of Gastroenterology, San Francisco, California, October 1990.     

Defecography

PURPOSE: This study was designed to analyze the frequency of different findings at defecography in patients with defecation disorders and see in what way the evaluation could be improved. METHODS: The reports of investigations in 2,816 patients were analyzed. RESULTS: Twenty-three percent of the investigations were considered normal. Thirty-one percent of the patients had rectal intussusception, 13 percent had rectal prolapse, 27 percent had rectocele, and 19 percent had enterocele. Twenty-one percent of the patients had a combination of two or three of these diagnoses. The combination of rectocele and enterocele was rare. The majority of patients with enterocele had other concomitant findings. Patients with or without abnormal perineal descent had similar frequencies of rectal prolapse, rectal intussusception, and enterocele. Rectocele was more common in patients with abnormal perineal descent. CONCLUSIONS: Defecography is valuable when investigating patients with defecation disorders. Pathologic findings were found in 77 percent of the patients. A standardized protocol should ensure a complete evaluation of defecography.Read in part at the 14th Biennial Congress of University Colon and Rectal Surgeons, Crete, Greece, October 25 to 29, 1992.     

Internal rectal intussusception: Results of surgical repair

Twenty-four patients with obstructed defecation due to rectal intussusception diagnosed by defecography were treated with rectopexy either by the Wells technique (9 patients) or by Orr's operation (15 patients). After follow-up from one to eight years, defecography demonstrated disappearance of the intussusception in 22 patients. None of the patients were completely relieved of their symptoms. Nine (41 percent; 95 percent confidence limits: 21–64) were improved and 13 were unchanged (59 percent; 95 percent confidence limits: 36–79), with no difference between the two procedures. One patient with solitary rectal ulcer was improved, and the ulcer disappeared. Four patients with moderate preoperative incontinence became continent postoperatively, but obstructed defecation was only improved in two of these patients. It is concluded that rectal intussusception is probably a secondary phenomenon in patients with obstructed defecation and that a conservative attitude toward surgery should be adopted.     

Enterocele is correctable using the Ripstein rectopexy

PURPOSE: About one-third of the patients with rectal prolapse or rectal intussusception have concurrent enterocele at defecography. The purpose of this study was to evaluate the effect of the Ripstein procedure on the concurrent enterocele and to study the outcome of the procedure with respect to the patients' symptoms. METHODS: Twenty-two patients with enterocele and either rectal prolapse or rectal intussusception at defecography were treated using the Ripstein procedure. Postoperatively, the patients were evaluated with clinical examination (22 patients) and defecography (16 patients). RESULTS: None of the patients had recurrence of enterocele, rectal prolapse, or intussusception at postoperative follow-up. Continence was improved in 15 of 16 incontinent patients. Emptying difficulties were unchanged in eight patients, improved in five patients, and had deteriorated in four patients. CONCLUSIONS: Enterocele is corrected by using the Ripstein rectopexy. Persisting defecation difficulties after the Ripstein procedure are unlikely to be secondary to enterocele. The Ripstein procedure can be an alternative in the treatment of enterocele, as a majority of these patients also have rectal prolapse or rectal intussusception.     

Evidence of electromechanical dissociation of the internal anal sphincter in idiopathic fecal incontinence

PURPOSE: This study was designed to evaluate the relationship between internal sphincter electromyographic frequency and ambulatory anal pressures in order to clarify the pathophysiology of internal anal sphincter dysfunction in fecal incontinence. METHODS: Seventytwo patients of median age 55 years (range, 24–75; 63 females) with neurogenic fecal incontinence and 33 normal subjects of median age 48.5 years (range, 25–74; 21 females) underwent fine-wire anal sphincter electromyography and anal manometry. RESULTS: The median internal anal sphincter electromyographic frequency was incontinent 0.25 Hz (0.2–0.34) and the control was 0.44 Hz (0.36–0.55;P<0.03). Ambulatory resting pressures were incontinent median 54 cm of H ₂ O (34–68 cm of H ₂ O) and control 94 cm of H ₂ O (72–102;P<0.01). Internal sphincter electromyographic frequency correlated with anal resting pressures in both groups (P<0.002). Internal sphincter electromyographic silence not attributable to electrode movement or the rectoanal inhibitory reflex, lasting 0.5 to 4 minutes occurred in all but two of the incontinent patients. The anal pressure during this period did not significantly change (P>0.1). No recruitment of the external sphincter or puborectalis was noted during these episodes. Such electromechanical dissociation was not seen in the control group. The frequency of transient internal sphincter relaxation was 4 (ranges 2–6) per hour in controls and 8 (ranges, 6–12) per hour in incontinent patients (P<0.01). Rectal pressures did not exceed midanal pressures in any of the controls but did in all of the incontinent patients on at least one occasion per hour in the incontinent group. CONCLUSION: Internal anal sphincter activity exhibits electromechanical dissociation and relaxes abnormally in incontinent patients.Supported by a separate equipment grant from the Scottish Hospital Endowment Research Trust.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.     

What affects continence after anterior resection of the rectum?

Functional results after anterior rectal resections are commonly considered satisfactory but variable percentages of postoperative incontinence are often reported. Continence was evaluated after 20 low anterior resections (LAR) and 13 high anterior resections (HAR) by means of clinical assessment, anorectal manometry, and evacuation proctography. Whereas all HAR patients had perfect continence, 10 patients (50 percent of the LAR group had occasional episodes of soiling from liquid feces, 5 patients (25 percent had frequent soiling or occasional incontinence for solid feces, and 1 patient (5 percent had frequent solid stool loss requiring surgical treatment. Anal canal resting pressure at 3 and 4 cm from the anal verge was significantly lower in the LAR group (P<0.02 and P<0.05, respectively) than in the HAR group. However, the maximum voluntary contraction did not differ between the two groups. Rectoanal inhibitory reflex was found to be present in 17 of the 20 patients with LAR and in all patients with HAR. The volume at which the anal sphincter is continuously inhibited was significantly reduced in the LAR group (P<0.001). Also, the conscious rectal sensibility volumes were found to be significantly reduced for threshold, constant, and maximum tolerated volume. Threshold volume for internal sphincter relaxation was lower than the threshold volume for rectal sensation in some patients with LAR. This could allow postoperative fecal soiling. Rectal compliance was decreased (P<0.001) in the LAR group. Evacuation proctography, performed in six LAR patients affected by major soiling or solid stool loss, revealed an abnormal obtuse anorectal angle and pathologic lowering of the perineum at rest and during defecation. The concomitance of internal anal sphincter impairment, reduction in rectal compliance, and previous pelvic floor muscle damage are postulated as cause affecting continence in patients who underwent LAR.Read at the Congress on Colo-Rectal Disease Milan, Italy, June 29–30, 1989.     

Does surgical repair of a rectocele improve rectal emptying?

PURPOSE: This study was undertaken to assess results of surgical repair of rectocele and to identify possible determinants of outcome from patient's history and preoperative defecography. Another aim was to evaluate how surgery affects rectal evacuation. METHOD: Thirty-four women with constipation and rectal emptying difficulties underwent surgery with a transanal technique. A preoperative defecography was performed in each patient. They were followed up after a median of 10 (range, 2–60) months with a questionnaire (n=34) and a defecography (n=31). Computer-based image analysis of defecographies was used to evaluate rectal evacuation. RESULTS: In 27 patients (79 percent), the result of surgery was good with subjectively improved emptying. The need for vaginal or perineal digitation preoperatively was related to a good result (P <0.05), whereas a previous hysterectomy (P <0.01) and a large rectal area on defecography (P <0.01) related to a poor result. Preoperative use of enemas, motor stimulants, or several types of laxatives also related to a poor outcome (P <0.05). Surgical treatment resulted in reduction of the rectocele (P <0.001), an elevated position of the anorectal junction (P <0.05), and improved rectal evacuation on defecographies (P <0.001). CONCLUSIONS: Surgical repair reduces the size of the rectocele and improves rectal emptying. These changes are accompanied by a symptomatic improvement in the majority of patients. Preoperative patient data and defecography may help in selecting patients for surgery.     

Results of rectocele repair

PURPOSE: This study was designed to evaluate the results of rectocele repair and parameters that might be useful in selecting patients for this operation. METHODS: Twentyfive patients with symptom-giving rectoceles were prospectively evaluated with a standardized questionnaire, physical examination, defecography, colon transit studies, anorectal manometry, and electrophysiology. Patients underwent posterior colporrhaphy and perineorrhaphy. They were followed postoperatively (mean, 1.0 year) with the same questionnaire, physical examination, defecography, anorectal manometry, and electrophysiology. RESULTS: Constipation had improved postoperatively in 21 of 24 constipated patients (88 percent). At postoperative follow-up 13 patients (52 percent) had no constipation symptoms, 8 (32 percent) had occasional symptoms, and 4 (16 percent) had symptoms more than once per week. Four patients with rectocele at preoperative defecography, but not at physical examination, had favorable outcomes following surgery. The majority of patients not using vaginal digitalization preoperatively had improved with respect to constipation. All patients with pathologic transit studies had various degrees of constipation postoperatively. Constipation was not improved in two of five patients with preoperative paradoxic sphincter reaction. CONCLUSIONS: Rectocele is one cause of constipation that can be treated with good results. Preoperative use of vaginal digitalization is not mandatory for a good postoperative result. Defecography is an important complement to physical examination. Patients with pathologic transit study might have a less favorable outcome of rectocele repair with respect to constipation. More studies about the significance of paradoxic sphincter reaction in these patients are indicated.Poster presentation at the XVth Biennial Congress of the International Society of University Colon and Rectal Surgeons, Singapore, July 2 to 6, 1994.     

Anal sphincter imaging in fecal incontinence using endosonography

Clinical anal examination, manometry (resting and squeeze pressures), and single-fiber electromyography were compared with endosonography of the anal sphincters in 14 patients with fecal incontinence. Technical aspects of the procedure and normal imaging of the puborectal muscle and both sphincters were defined. Defects in both sphincters were seen in nine patients. The defect is visualized as a clear discontinuity in the muscular ring. Compared with the conventional studies, anal endosonography gave significant information in six patients (four male patients after perianal surgery and two women), showing sphincter defects in five patients and integrity of the sphincters in another one. This information obtained by endosonography was important in understanding the type and extension of the lesion and deciding upon the surgical repair. Anal endosonography is an imaging technique of the sphincters that can assess their integrity in fecal incontinence.     

Combined anorectal manometry and defecography in 50 consecutive adults with fecal incontinence

Fifty consecutive patients presenting with fecal incontinence were evaluated prospectively with anorectal manometry, defecography, and other tests of anorectal function to assess the clinical utility of defecography in fecal incontinence. Leakage of contrast at rest and failure to narrow the anorectal angle with pelvic squeezing were specific but not sensitive predictors of decreased sphincter pressures as determined by manometry. Thus, after manometry, defecography provided no additional information regarding sphincter strength. Retention of contrast in large rectoceles or incomplete rectal evacuation at defecography had excellent correlation with the presence of clinical symptoms of outlet obstruction constipation (present concurrently with incontinence) and indicated an etiology of outlet obstruction symptoms. Defecography may provide useful information in incontinent patients with outlet obstruction constipation symptoms but has little additive value to anorectal manometry in incontinent patients without such symptoms.