Analysis of patients with poor outcome of rectocele repair

PURPOSE: The aim of the present study was to analyze the prognostic value of clinical data and physiologic tests in patients undergoing rectocele repair for obstructed defecation. METHODS: Between 1988 and 1996, 89 consecutive female patients with obstructed defecation caused by a rectocele were enrolled in the study. Median age at time of presentation was 55 (range, 35–81) years. All patients underwent a combined transvaginal and transanal rectocele repair. End evaluation to assess long-term results was performed by an independent observer after a median duration of follow up of 52 (range, 12–92) months. The presence of the following five symptoms was evaluated: prolonged and unsuccessful straining at stool, feelings of incomplete evacuation, manual assistance during defecation, false urge to defecate, and a stool frequency of less than three times per week. When none or just one of these symptoms was present, outcome of rectocele repair was considered successful. The outcome was considered as a failure when two or more of these symptoms were recorded. Furthermore, all patients were asked to score the outcome of their operations as excellent, good, moderate, or poor. Clinical data and the results of physiologic tests obtained in patients with a poor outcome of surgery were compared with those obtained in patients with a successful outcome. RESULTS: Objective outcome of rectocele repair, based on the presence of symptoms, was found to be successful in 63 (71 percent) patients. Sixty-one patients considered outcome of surgery excellent or good (69 percent). Graded subjective outcomes between the two groups showed significantly better grades in cases of success. Duration of symptoms, number of symptoms, age, parity, and previous hysterectomy had no influence on the final outcome of surgery. Defecographic parameters, such as size of the rectocele, barium trapping in the rectocele, poor rectal evacuation, or intussusception, had no prognostic value. Signs of anismus based on defecography, electromyography, and balloon-expulsion studies did not influence outcome of surgery. The presence of symptoms such as defecation frequency, manual assistance, severe straining, false urge to defecate, or feelings of incomplete evacuation had no impact on the outcome. However, in patients without a daily urge to defecate or with a stool frequency of less than once per week, results of rectocele repair were significantly worse than in patients with a daily urge to defecate or a defecation frequency of more than once per week or both. In 14 of 26 patients with a poor outcome, colonic transit studies were performed. A delayed passage was observed throughout the entire colon in seven patients, in the left part of the colon and the rectosigmoid colon in four patients, and in the rectosigmoid colon in one patient. In two patients colonic transit was normal. CONCLUSIONS: Combined transvaginal and transanal rectocele repair is beneficial for the majority of patients with obstructed defecation. In patients without a daily urge to defecate or a stool frequency of less than once per week, indicating colonic malfunctioning, the outcome of rectocele repair seems to be poor.     

Paradoxical puborectalis contraction is associated with impaired rectal evacuation

The role of paradoxical puborectalis contraction in the aetiology of constipation and how to best diagnose this condition is controversial. The aims of this study were to investigate whether absolute or relative paradoxical electrical activity during electromyography (EMG) are related to rectal emptying and to compare EMG, defecography and digital examination in the diagnosis of paradoxical puborectalis contraction. Included in the study were 171 consecutive patients with idiopathic constipation; 136 of these cases were also classified as paradoxical or unclear or not paradoxical at digital examination. Absolute amplitudes and a strain/squeeze index were used to grade the EMG activity in the puborectalis and external sphincter muscle. Rectal evacuation was analysed by defecography with image analysis of rectal area. The results showed that 142 patients had paradoxical EMG activity during straining. There was a correlation between rectal evacuation and amplitudes (r=–0.20 to –0.03, P<0.01) and between evacuation and index (r=–0.34 to –0.39, P<0.0001). Forty-two patients with an index of >50 had impaired rectal evacuation compared with those with an index ≤50 (P<0.0001). Thirty-three of 34 cases (n=136) with an index of >50 also were paradoxical at defecography whereas 19 were diagnosed digitally. In conclusion, paradoxical puborectalis contraction is associated with impaired rectal evacuation. The activity seems to be best reflected by a strain/squeeze index. The best correlation in diagnostic methods was between EMG and defecography. Accepted: 10 February 1998     

Comparative study between intra-anal sponge and needle electrode for electromyographic evaluation of constipated patients

PURPOSE: The aim of this study was to compare the intraanal sponge electrode with the conventional needle electrode for electromyography of the pelvic floor in constipated patients. MATERIALS AND METHODS: Forty consecutive patients (27 females) with a mean age of 64.3 (range, 15–87) years who had chronic constipation were prospectively evaluated for electromyographic evidence of nonrelaxation or paradoxical contraction of the puborectalis and external anal sphincter during simulated defecation. The soft intra-anal sponge electrode and then the concentric needle electrode were used in each patient as an internal control. Furthermore, in all patients, cinedefecography was used as an independent standard to confirm the diagnosis. Agreement was calculated using the kappa statistic. RESULTS: Confirmation of needle electromyography was noted in 19 of 20 patients (95 percent) who had sponge electromyographic evidence of paradoxical activity. Similarly, concurrence was noted in 19 of 20 patients (95 percent) with normal relaxation of the puborectalis observed with the sponge electrode. Agreement between needle and sponge electromyography was very good (=0.9), between needle electromyography and cinedefecography was fair (=0.4), and between sponge electromyography and cinedefecography was moderate (=0.5). Furthermore, needle electromyography was more painful in all aptients compared with sponge electromyography. CONCLUSION: The soft sponge surface intra-anal electrode is an excellent alternative to the needle electrode for assessment of puborectalis activity in constipated patients. Sponge electromyography has the advantage of being as accurate as, but less painful than, needle electromyography.Funded in part by a research grant from the Eleanor Naylor Dana Foundation.Read at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.     

Electromyography of the external anal sphincter

PURPOSE: Electromyography of the external anal sphincter is frequently used when investigating patients with defecation disorders. Investigations are often performed using an invasive technique by perineal insertion of a needle or wire electrode. The aim of the present study was to investigate whether surface electromyography, with electrodes applied to the perineal skin, is a reliable method in the diagnosis of paradoxical anal sphincter reaction. METHODS: Seventy-one patients with defecation disorders participated in the present study. They were investigated with electromyography of the external anal sphincter using surface and needle electrodes. RESULTS: In 65 of 71 (92 percent) patients the electromyography recording showed the same result during straining using surface electrodes when compared with needle electrodes. Twenty-two of these 65 patients had paradoxical anal sphincter reaction, and 43 patients had decreased electromyography activity. In 6 of 71 (8 percent) patients the electromyography recording showed a different pattern during straining using surface electrodes when compared with needle electrodes. CONCLUSION: The present study demonstrates a good correlation between surface electrodes applied to the perineal skin and concentric needle electrodes in the diagnosis of paradoxical anal sphincter reaction. Noninvasive electromyography recordings of the external anal sphincter are often preferred in the diagnosis of paradoxical anal sphincter reaction.Supported by grants from Kjell and Märta Beijers Stiftelse, Marianne and Marcus Wallenbergs Stiftelse, Bert von Kantzow's Research Foundation, and Karolinska Institutet Research Funds.     

Efficacy and safety of botulinum toxin in treatment of anismus: A systematic review

AIM: To evaluate the efficacy and safety of botulinum toxin type A(BTX-A) in the management of patients with anismus. METHODS: An organized search of published literature was conducted using electronic databases including: Pub Med/MEDLINE, and Cochrane Central Register of Control ed Trials, also an internet-based search using "Google Scholar" service was conducted. Both comparative and observational studies were included. We excluded irrelevant articles, editorials, case reports, reviews, and meta-analyses. The studies that followed the patients less than 6 mo were excluded. Variables collected were demographic data of the patients, technique of BTX-A injection and number of sessions, short-term and longterm clinical improvement, post-injection changes in electromyography(EMG), defecography, manometry, and balloon expulsion test, and complications recorded after BTX-A injection.RESULTS: Seven studies comprising 189 patients were included in the review. The median age of the patients was 41.2 years and female-to-male ratio was 1.3:1. The median dose of BTX-A injected per procedure was 100 IU(range, 20-100 IU). Lateral injection was done in five trails and combined lateral and posterior injections in two trials. Three studies used endorectal ultrasonographyguided technique, one study used EMG-guided technique,whereas the remaining three studies used manual palpation with the index finger. The median percentage of patients who reported initial improvement of symptoms was 77.4%(range 37.5%-86.7%), this percentage declined to a median of 46%(range 25%-100%) at 4 mo after injection of BTX-A. Rates of improvement evaluated by balloon expulsion test, EMG, and defecography ranged between(37.5%-80%),(54%-86.7%), and(25%-86.6%), respectively. Fourteen(7.4%) patients developed complications after injection of BTX-A. Complication rates across the studies ranged from 0% to 22.6%. CONCLUSION: Initial satisfactory improvement of symptoms after BTX-A injection remarkably deteriorated after 3 mo of the procedure. However, repeated injection may provide better sustained results with no additional morbidities. Further analysis of more patients is necessary to conclude the safety of BTX-A for the treatment of anismus.     

排粪造影力排时与提肛时肛直角及其变化诊断盆底失弛缓征的价值

目的：提高盆底失弛缓征排粪造影诊断水平。方法：回顾性分析45例明确诊断为盆底失弛缓征患者及20例排便正常者的排粪造影X线影像,在侧位照片上测量力排时和提肛时的肛直角（ARA）,并计算两组的肛直角差。结果：病例组力排时和提肛时肛直角及其差分别为（96.8±3.9）°、（85.3±2.1）°、（9.8±5.1）°,对照组分别为（120.5±7.8）°、（80.2±6.5）°、（41.6±3.9）°,两组肛直角差之间差异有极显著性意义（P〈0.01）。其中,27例盆底痉挛综合征患者力排时和提肛时肛直角变化较小,为（7.6±1.8）°,且力排肛直角〈90°;15例耻骨直肠肌综合征患者力排、提肛肛直角变化很小,仅（2.8±1.3）°,且力排肛直角≤90°;3例肛门内括约肌失弛缓综合征患者力排肛直角增大（〉100°）,肛直角差较大,为（12.6±4.1）°。三者两两比较肛直角差之间差异存在极显著性意义（P〈0.01）。结论：提肛、力排肛直角及其变化对盆底失弛缓征的诊断有重要价值。     

This Month in Scandinavian Journal of Gastroenterology

Background: The purpose of this study was to compare the manometric assessment of straining effort as if to defecate and rectoanal inhibitory reflex obtained with a rectosphincteric balloon probe and with a waterperfused catheter in the same subject. Methods: Twelve healthy volunteers underwent two manometric assessments of anal sphincter function and electromyographic (EMG) surface recordings, one with a rectosphincteric balloon and one with a water-perfused catheter, 7 days apart in random order. Results: Increased EMG activity in the external anal sphincter in the midst of the rectoanal inhibitory reflex ( P < 0.001) and during straining for defecation ( P < 0.001) was more frequently observed with the perfused system than with the balloon probe. There was a discrepancy between the EMG activity of the external anal sphincter and the anal pressures during straining recorded with the perfused system. Duration of the reflex elicited by rectal distension with 10 and 20 ml of air was significantly greater with the rectosphincteric balloon than with the perfused catheter ( P = 0.02 and P = 0.05, respectively). Conclusion: Water instilled in the anal canal by the perfused system induces artifacts in EMG recording and active anal contractions. These artifacts and induced contractions could lead to an erroneous diagnosis of anismus, particularly if pelvic floor EMG is only taken into account for the diagnosis of anismus.     

Botulinum toxin type-A injection to treat patients with intractable anismus unresponsive to simple biofeedback training

AIM: To evaluate the efficacy of botulinum toxin type A injection to the puborectalis and external sphincter muscle in the treatment of patients with anismus unresponsive to simple biofeedback training.METHODS: This retrospective study included 31 patients suffering from anismus who were unresponsive to simple biofeedback training. Diagnosis was made by anorectal manometry, balloon expulsion test, surface electromyography of the pelvic floor muscle, and defecography. Patients were given botulinum toxin type A (BTX-A) injection and pelvic floor biofeedback training. Follow-up was conducted before the paper was written. Improvement was evaluated using the chronic constipation scoring system.RESULTS: BTX-A injection combined with pelvic floor biofeedback training achieved success in 24 patients, with 23 maintaining persistent satisfaction during a mean period of 8.4 mo.CONCLUSION: BTX-A injection combined with pelvic floor biofeedback training seems to be successful for intractable anismus.