Anorectal function in the solitary rectal ulcer syndrome

The anorectal function of nine patients with solitary rectal ulcer syndrome (SRUS) (5 F: 4 M, median age, 27 (range, 19–41 years) and nine control subjects (5 F: 4 M, median age, 47 (35–66)P<0.01) has been investigated by a new technique that radiologically visualizes the anorectum during voiding of a semisolid contrast medium, while simultaneously measuring intrarectal pressure and anal sphincter EMG activity. A degree of rectal prolapse was demonstrated in eight of the SRUS patients; six of these lesions were clinically occult. Abnormal failure of the anal sphincter to relax on voiding was present in seven of the SRUS patients. These abnormalities resulted in the SRUS patients requiring a greater increase in intrarectal pressure (median, 100 cm water) to void than the control subjects (median, 65 cm water,P<0.01). This combination of high intrarectal pressure and rectal prolapse during straining seems to be the cause of SRUS This work was supported by a grant from the Medical Research Council.     

Barium proctography vs magnetic resonance proctography for pelvic floor disorders: a comparative study

Aim Accurate and reliable imaging of pelvic floor dynamics is important for tailoring treatment in pelvic floor disorders; however, two imaging modalities are available. Barium proctography (BaP) is widely used, but involves a significant radiation dose. Magnetic resonance (MR) proctography allows visualization of all pelvic midline structures but patients are supine. This project investigates whether there are measurable differences between BaP and MR proctography. Patient preference for the tests was also investigated. Methods Consecutive patients referred for BaP were invited to participate (National Research Ethics Service approved). Participants underwent BaP in Poole and MR proctography in Dorchester. Proctograms were reported by a consultant radiologist with pelvic floor subspecialization. Results A total of 71 patients were recruited. Both tests were carried out on 42 patients. Complete rectal emptying was observed in 29% (12/42) on BaP and in 2% (1/42) on MR proctography. Anismus was reported in 29% (12/42) on BaP and 43% (18/42) on MR proctography. MR proctography missed 31% (11/35) of rectal intussusception detected on BaP. In 10 of these cases no rectal evacuation was achieved during MR proctography. The measure of agreement between grade of rectal intussusception was fair (κ = 0.260) although MR proctography tended to underestimate the grade. Rectoceles were extremely common but clinically relevant differences in size were evident. Patients reported that they found MR proctography less embarrassing but harder to empty their bowel. Conclusions The results demonstrate that MR proctography under‐reports pelvic floor abnormalities especially where there has been poor rectal evacuation.     

Imaging of the posterior pelvic floor

Disorders of the posterior pelvic floor are relatively common. The role of imaging in this field is increasing, especially in constipation, prolapse and anal incontinence, and currently imaging is an integral part of the investigation of these pelvic floor disorders. Evacuation proctography provides both structural and functional information for rectal voiding and prolapse. Dynamic MRI may be a valuable alternative as the pelvic floor muscles are visualised, and it is currently under evaluation. Endoluminal imaging is important in the management of anal incontinence. Both endosonography and endoanal MRI can be used for detection of anal sphincter defects. Endoanal MRI has the advantage of simultaneously evaluating external sphincter atrophy, which is an important predictive factor for the outcome of sphincter repair. Many aspects of constipation and prolapse remain incompletely understood and treatment is partly empirical; however, imaging has a central role in management to place patients into treatment-defined groups.     

Evacuation proctography combined with positive contrast peritoneography to demonstrate pelvic floor hernias

Background To demonstrate the pelvic peritoneal recesses during voiding, evacuation proctography was combined with positive contrast peritoneography.Methods In 30 constipated patients, peritoneography was performed, followed by proctography.Results During evacuation rectogenital herniation developed in 20 patients (66%), without visceral filling in 12 (40%).Conclusions Posterior pelvic floor hernia is common during defecation. Less than half fill with bowel and many may not be apparent on standard proctography.     

Relationship between anatomic and symptomatic long-term results after rectocele repair for impaired defecation

PURPOSE: The aim of this study was to determine the long-term symptomatic and anatomic results of rectocele repair for impaired defecation. METHODS: All 26 females operated on during a five-year period in one hospital were reviewed in clinic. Follow-up was available on 22 patients after a median of 27 (range, 5–54) months. Interview, anorectal physiological testing, and evacuation proctography were performed preoperatively and postoperatively. Fifteen patients had a transperineal repair and seven patients had a transanal repair. RESULTS: Sixteen (73 percent) patients felt improved. A feeling of incomplete emptying (19vs. 10, preoperativevs. postoperative;P=0.02) and the need to use digital assistance vaginally (13vs. 6;P=0.07) were both reduced by surgery, the former being improved significantly more often after transperineal repair. The rectocele width and area were reduced by both types of surgery; however, the rectocele diameter was greater than 2 cm in 16 patients preoperatively and 10 patients postoperatively. There was no significant difference between patients who did or did not feel improved by surgery in the percentage reduction in rectocele width (22vs. 18 percent;P=0.95), the percentage reduction in rectocele area (65vs. 62 percent;P=0.95), or a rectocele width of more than 2 cm (44vs. 50 percent;P=0.80), didvs. did not feel improved, respectively. CONCLUSION: Operative repair symptomatically improves a majority of patients with impaired defecation associated with a large rectocele, but the improvement probably relates at least in part to factors other than the dimensions of the rectocele.     

Intraobserver variation in the radiological measurement of the anorectal angle

Seven experts drew the rectal axes of 18 representative proctographic images on two occasions, with a 1-year interval, in order to assess intraobserver variation in the determination of the anorectal angle (ARA). Intraobserver variation (6%) and interobserver variation (17%) were smallest when the central rectal axis was used to determine the ARA. A strong relation was found between inter- and intraobserver variation (r=0.77). Intraobserver variation tended to be rather small for pictures made during straining, but a relation with the magnitude of the ARA was not found. Although none of the seven experts could reproduce the rectal axes with 10% variation in all 18 pictures, redrawing of the central rectal axis delivered 10% variation in 86% of determinations. It is concluded that intraobserver variation is influenced by the expertise of the investigator, the method of analysis, and the anorectal configuration to be analyzed. Radiologic assessment of the ARA may yield reliable data on the dynamics of the anorectum if performed by a single investigator on x-ray films that allow confident analysis.     

Evacuation proctography: An investigation of rectal expulsion in 20 subjects without defecatory disturbance

Evacuation proctography is a dynamic investigation of rectal expulsion that records the voluntary evacuation of thick barium paste on videotape. Evacuation is a passive phenomenon in a defined zone of the rectum, associated with pelvic floor descent of 3 cm from a resting position of the anorectal junction <2 cm above the plane of the ischial tuberosities. The anal canal does not open immediately; it takes about 4.5 sec to open to a maximum diameter of 1.5 cm, with rectal emptying in 11 sec. Anterior rectoceles commonly invert over the anal canal as the rectum collapses in at the end of evacuation.