Search

INTRODUCTION: Normal bowel function requires intact sensory pathways. Diminished rectal sensation (rectal hyposensitivity [RH]) is associated with constipation, although its clinical importance remains unclear. METHODS: Consecutive patients (aged 18-80) attending a tertiary center (2004-2016) for investigation of refractory functional constipation (Rome IV core criteria defined, applied post hoc) were included. Patients completed a clinical symptom questionnaire and underwent anorectal physiologic investigations, including rectal sensory testing (balloon distension) to determine 3 well-established sensory thresholds. Multivariate regression analyses were performed to evaluate associations between RH, symptomology, and allied physiologic investigations. RESULTS: Of 2,876 patients meeting inclusion criteria, 722 (25%) had RH based on ≥1 elevated sensory thresholds (0: n = 2,154 [74.9%]; 1: n = 327 [11.4%]; 2: n = 209 [7.3%]; and 3: n = 186 [6.5%]). A linear relationship existed between increasing number of elevated sensory thresholds and constipation severity (Cleveland Clinic constipation score: mean difference per threshold [95% confidence interval] 0.69 [0.48-0.90]; P < 0.001). Several symptoms were significantly (P < 0.05) associated with RH including: infrequent defecation (odds ratio 1.29 [1.17-1.42]), painful evacuation (1.15 [1.05-1.27]), prolonged toileting (1.14 [1.05-1.24]), and digitation or enema use (1.18 [1.08-1.30]). On defecography, a "functional" evacuation disorder was also associated with RH (1.37 [1.25-1.50], P < 0.001), as was megarectum (2.52 [2.08-3.05], P < 0.001). DISCUSSION: RH occurs in 25% of patients with refractory functional constipation. Increased number of elevated sensory thresholds is associated with more severe constipation phenotype. These data, in the largest study to date, provide for the first time evidence to show that RH is a major pathophysiologic mechanism in constipation, with recognized clinical impact (http://links.lww.com/AJG/B765). [ABSTRACT FROM AUTHOR]

Background & Aims: Functional gastrointestinal disorders are prevalent worldwide and alterations of gutbrain axis and intestinal barrier integrity may play a pivotal role in both the pathophysiology and clinical course of these bowel malfunctions. We aimed to assess the prevalence of abdominal pain in a selected adult population of Poland to determine potential environmental factors associated with gastrointestinal complaints. Methods: There were 1479 individuals - 657 women (44.42%) and 822 men (55.58%), aged 24.20±6.08 years. The responders fulfilled an authors' questionnaire based on Rome II and III criteria focused on the abdominal pain prevalence and environmental factors involved in its occurrence. Results: The frequency of abdominal pain was found to be as high as 19.2%. Male gender (n=822) and basic education level (n=151) lowered the risk of abdominal pain occurrence (OR=0.7, p<0.012 and OR=0.5, p<0.021, respectively). Psychological distress, proton pump inhibitors (PPIs) and antibiotics usage were found as risk factors of abdominal pain (OR=2.503, p<0.01; OR=3.308, p<0.01; OR=3.105, p<0.01, respectively). Conclusions: Abdominal pain is prevalent in young adult inhabitants of Poland, especially in women. Intense psychological stress, as well as PPIs and antibiotics usage elevate the risk. [ABSTRACT FROM AUTHOR]

Purpose: To compare the time-course change in the postoperative anorectal function between laparoscopic intersphincteric resection (ISR) and low anterior resection (LAR).Methods: This is a single-institution observational study. We evaluated the time-course change in the anorectal function using functional questionnaires before and at 6, 12, and 24 months after laparoscopic ISR or LAR.Results: Sixty-two patients answered the functional questionnaires (28 in the ISR group and 34 in the LAR group). In the ISR group, the Wexner scores at 6, 12, and 24 months postoperatively were significantly higher than preoperatively. Importantly, the Wexner score at 24 months postoperatively was significantly lower than that at 6 months postoperatively. The low GIFO scores at 6 and 12 months postoperatively tended to be recovered to some extent at 24 months postoperatively. In the LAR group, Wexner score at 6 months postoperatively was significantly higher than that preoperatively. Notably, the Wexner score at 12 months postoperatively was recovered to almost the same as that preoperatively. The GIFO scores at 12 months postoperatively were mostly recovered to the same levels as those preoperatively.Conclusions: Laparoscopic ISR exhibits different time-course changes in the anorectal function from laparoscopic LAR. [ABSTRACT FROM AUTHOR]

Aim: We have developed an imaging functional assessment of defecation after partial intersphincteric resection (ISR) by fecoflowgram obtained by defecography. Patients and Methods: Between January 2012 and December 2014, 6 patients with temporary ileostomy who underwent partial ISR for lower rectal cancer at our hospital were enrolled in this study. Defecography was performed 2 weeks after closure of the ileostomy. The defecation of all patients was evaluated by defecography and a fecoflowgram calculated from defecography. During the same period, the control group was comprised of 2 male and 2 female healthy volunteers. Results: The descent of the perineum and linearization of the anorectal angle was observed relative to normal defecation in the healthy volunteers. All barium was discharged by a single abdominal pressure within 5 s in the controls. In patients after partial ISR, all barium could not be discharged by a single abdominal pressure. The time course of pressure distribution after ISR was lower than that of healthy volunteers, which could not be evaluated by defecography. Defecation time in patients following ISR was longer than that of healthy volunteers. Conclusion: Fecoflowgrams calculated from defecography seem to be useful for functional assessment of defecation after rectal resection. [ABSTRACT FROM AUTHOR]

Abstract Background Electrogastrography (EGG) is a noninvasive technique for recording gastric myoelectric activity. The aim of this study was to measure and record gastric myoelectric activity in patients with obstructed defecation syndrome (ODS) and to compare their results with those of normal individuals. Methods Forty-two patients (22 male) with ODS and a mean age of 41.02 y were enrolled in this prospective study after thorough clinical and physiologic assessment. Eleven normal subjects (six female) with a mean age of 39.2 ± 8.4 y were assigned to the control group. Both patients and controls were subjected to surface EGG in fasting and postprandial states. Data were recorded and analyzed via a computer system to reveal the EGG pattern in both groups. Results Abnormalities in the EGG were found in 24 (57.1%) of the 42 patients with ODS. EGG in ODS patients showed alterations in the fasting state in the form of a significant decrease of the normal gastric slow wave ( P = 0.03) and a nonsignificant increase in gastric dysrhythmias. The EGG alterations of ODS patients were significantly improved in the postprandial state as the normal gastric slow waves significantly ( P = 0.006) increased and the gastric bradycardia declined significantly ( P = 0.02). No significant differences were observed in the power distribution between the ODS patients and the healthy controls. Conclusions Patients with ODS showed an altered EGG pattern compared with that of healthy control subjects. The alterations in ODS patients were more clearly observed during the fasting state and improved significantly after eating. [ABSTRACT FROM AUTHOR]

Background: Huntington’s disease (HD) patients often report anorectal dysfunction; however, in HD research no detailed analysis of these complaints has been published. Objective: To report anorectal dysfunction in a systematically studied cohort of HD subjects. Methods: In 54 HD patients (24 men) and 10 presymptomatic HD mutation carriers (2 men) and in 99 controls (44 men) a history of anal incontinence and constipation was obtained and data was compared accordingly. In HD mutation carriers a clinical neurologic assessment and in some cases anorectal manometry were performed. Results: Defecation urgency was reported by 28% of our HD mutation carriers, soiling in 18% and fecal incontinence in 28%. Severe anal incontinence (solid stools) was found in 0% men / 10% women, moderate (liquid stools) in 21% / 13%, and mild (flatus only) in 67% / 47% of our HD subjects. Compared to controls, anal incontinence was significantly more common in HD subjects (p < 0.001). Severe chronic constipation was found in 4.2% men / 0.0% women, moderate in 8.3% / 0.0%, and mild in 21% / 27% of HD subjects. Constipation was more common in HD men (p = 0.02) than in HD women (p = 0.144). Anorectal dysfunction was not reported by 54% of our HD subjects. Patients reporting incontinence or constipation were significantly more depressed (r = 0.53, p = 0.001). Upon anorectal manometry reduced resting anal pressure was found in 4 of 6 HD women. Conclusions: Our study demonstrated significant bowel dysfunction in HD patients. We propose these symptoms to be of central autonomic origin, although we cannot exclude effects of medication. These often neglected symptoms in HD subjects require greater attention from physicians. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

A 50-day-old male Maltese puppy was presented with difficulty in defaecation. Based on the clinical signs, and physical and radiographic examinations, including computed tomography, his condition was diagnosed as hypospadias, along with atresia ani and urethrorectal fistula. Hypospadias is a congenital malformation of the urethra that is relatively uncommon in dogs, while atresia ani is a rare congenital anomaly of the rectum and anus. An additional anatomic abnormality that can be associated with atresia ani is a fistula between the urogenital tract and rectum. After appropriate surgical procedures, the puppy recovered and defaecation via the anus was restored. [ABSTRACT FROM AUTHOR]

Background: The aim of the present study was to evaluate the diagnostic accuracy of magnetic resonance (MR) defecography and compare it with videodefecography in the evaluation of obstructed defecation syndrome. Methods: This was a prospective cohort test accuracy study conducted at one major tertiary referral center on patients with a diagnosis of obstructed defecation syndrome who were referred to the colorectal surgery clinic in a consecutive series from 2009 to 2012. All patients underwent a clinical examination, videodefecography, and MR defecography in the supine position. We analyzed diagnostic accuracy for MR defecography and performed an agreement analysis using Cohen's kappa index (κ) for each diagnostic imaging examination performed with videodefecography and MR defecography. Results: We included 40 patients with Rome III diagnostic criteria of obstructed defecation syndrome. The degree of agreement between the two tests was as follows: almost perfect for anismus ( κ = 0.88) and rectal prolapse ( κ = 0.83), substantial for enterocele ( κ = 0.80) and rectocele grade III ( κ = 0.65), moderate for intussusception ( κ = 0.50) and rectocele grade II ( κ = 0.49), and slight for rectocele grade I ( κ = 0.30) and excessive perineal descent ( κ = 0.22). Eighteen cystoceles and 11 colpoceles were diagnosed only by MR defecography. Most patients (54%) stated that videodefecography was the more uncomfortable test. Conclusions: MR defecography could become the imaging test of choice for evaluating obstructed defecation syndrome. [ABSTRACT FROM AUTHOR]

OBJECTIVE Fecal incontinence (FI) and constipation can arise from a variety of alterations of anorectal function. This study aimed to investigate the components of the anorecal reflex in patients with these symptoms and to determine the functional significance of various physiological parameters. METHODS Altogether 21 healthy volunteers (controls) and 78 FI-predominant and 74 constipation-predominant patients were recruited and administered Wexner incontinence and constipation questionnaires. All participants underwent standardized anorectal physiology assessments. RESULTS Patients with passive FI had lower resting sphincter pressures than controls (38 cmH2O vs 87 cmH2O, P < 0.05), while those with urge FI had lower squeeze pressures than controls (37 cmH2O vs 119 cmH2O, P < 0.05). Patients with urge FI had lower maximal tolerable volumes (100 mL vs 166 mL, P < 0.05). Patients with slow-transit constipation had elevated rectal electrosensitivity thresholds compared with controls (31.4 mA vs 20.2 mA, P < 0.05), and rectal mucosal blood flow than patients with evacuation difficulty and controls (107 vs 162 flux units (FU) [evacuation difficulty] vs 169 FU [controls], P < 0.05). Only patients with passive FI were associated with reflex abnormalities (prolonged recovery phase (1.2 ms vs 0.5 ms, P < 0.05) and total duration of reflex (6.3 ms vs 4.3 ms, P < 0.05). CONCLUSIONS Anorectal motor, sensory and reflex abnormalities are seen in distinct patterns in patients with FI and constipation. This would suggest distinct physiological differences that may predict the potential for different neuromodulation treatment and behavioral modalities in these conditions. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: To compare the effect of laparoscopic and robot-assisted ventral rectopexy for posterior compartment procidentia on the pelvic floor anatomy and function. Methods: A prospective randomised single-centre study was carried out of 29 female patients, who underwent robot-assisted or laparoscopic ventral mesh rectopexy for external or internal rectal prolapse with symptoms of obstructive defecation and/or faecal incontinence. Anatomical changes were measured by Pelvic Organ Prolapse Quantification (POP-Q) and magnetic resonance defecography. Functional changes were evaluated using symptom questionnaires before and 3 months after surgery. Results: After rectopexy, changes in POP-Q measurements were statistically significant for points Ap, Bp, C, D and Ba. The descent of the anorectum and cervix/vaginal cuff during straining were significantly reduced with regard to the reference line (mean, −10.4 ± 14.9 mm, p = 0.001) and (−13.3 ± 18.1 mm, p < 0.001) respectively. Pelvic organ mobility (POM) was reduced statistically significantly for the posterior (mean, −16.6 ± 20.8 mm, p < 0.001) and apical compartments (mean, −13.1 ± 14.8, p < 0.001). The PFDI-20, PFIQ-7 and PISQ-12 questionnaires showed statistically significant improvement of symptoms and sexual function. No significant differences were observed between the robot-assisted and laparoscopic techniques in terms of anatomical or functional parameters. Conclusion: Ventral mesh recto-colpo-sacropexy effectively corrects the anatomy of the posterior compartment, elevates the vaginal apex and reduces pelvic organ mobility of the posterior and middle compartments. The robot-assisted and laparoscopic techniques had similar anatomical and functional outcomes. [ABSTRACT FROM AUTHOR]

Background Evacuatory dysfunction ( ED) is a common cause of constipation and may be sub-classified on the basis of specialist tests. Such tests may guide treatment e.g., biofeedback therapy for 'functional' defecatory disorders ( FDD). However, there is no gold standard, and prior studies have not prospectively and systematically compared all tests that are used to diagnose forms of ED. Methods One hundred consecutive patients fulfilling Rome III criteria for functional constipation underwent four tests: expulsion of a rectal balloon distended to 50 mL ( BE50) or until patients experienced the desire to defecate ( BEDDV), evacuation proctography (EP) and anorectal manometry. Yields and agreements between tests for the diagnosis of ED and FDD were assessed. Key Results Positive diagnostic yields for ED were: BEDDV 18%, BE50 31%, EP 38% and anorectal manometry ( ARM) 68%. Agreement was substantial between the two balloon tests ( k = 0.66), only fair between proctography and BE50 ( k = 0.27), poor between manometry and proctography ( k = 0.01), and there was no agreement between the balloon tests and manometry ( k = −0.07 for both BE50 and BEDDV). For the diagnosis of FDD, there was only fair agreement between ARM and EP ( k = 0.23), ARM ± BE50 and EP ( k = 0.18), ARM and EP ± BE50 ( k = 0.30) and ARM ± BE50 and EP ± BE50 ( k = 0.23). Conclusions & Inferences There is considerable disagreement between the results of various tests used to diagnose ED and FDD. This highlights the need for a reappraisal of both diagnostic criteria, and what represents the 'gold standard' investigation. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the role of dynamic MR defecography before rectal filling in detecting occult anterior compartment prolapse in patients with obstructed defecation. Methods: This prospective study was approved by the ethics committee. Seventy six females with obstructed defecation underwent dynamic MR defecography before and after rectal filling. Pre-rectal and post-rectal filling sequences were interpreted separately by two radiologists on two different settings with a time interval of one week. Statistical analysis was performed using Wilcoxon's-matched-pairs signed rank test and t-test for matched pairs; differences were considered statistically significant at p<0.05. Results: Fifty eight females of 76 showed additional anterior compartment derangement, with 27 diagnosed only in pre-rectal filling sequence (27/58=46.55%). Following rectal filling detected cystocele in 27 patients was not identified in 14 cases and downgraded in 13. Similarly, detected uterine prolapse in 17 patients was not visualized in 14 patients and downgraded in 3. Furthermore, rectocele was identified in 7 cases before gel enema, additional 32 detected after rectal filling. Significant statistical difference in the detection of both cystocele (p=0.0001) and uterine prolapse (p=0.0013) was identified in the non-filled sequence. Conclusion: Pelvic floor imaging before rectal filling is significantly better for detection of anterior compartment prolapse. [ABSTRACT FROM AUTHOR]

Aim Restorative proctocolectomy ( RPC) with ileal pouch-anal anastomosis ( IPAA) is the most frequently performed operation for intractable ulcerative colitis ( UC) and for many patients with familial adenomatous polyposis ( FAP). It can be complicated by a functional evacuation difficulty, which is not well understood. We aimed to evaluate the role of defaecating pouchography in an attempt to assess the mechanism of evacuation difficulty in pouch patients. Method All RPC patients who had had a defaecating pouchogram for evacuation difficulty at one hospital between 2006 and 2014 were retrospectively reviewed. The findings and features were correlated with the symptoms. Demographic, clinical and radiological variables were analysed. Results Eighty-seven [55 (63%) female] patients aged 47.6 ± 12.5 years (mean standard ± SD) were identified. Thirty-five had a mechanical outlet obstruction and 52 had no identified mechanical cause to explain the evacuation difficulty. The mean age of these 52 [33 (63%) female] patients was 48.2 ± 13 years. Of these 52 patients, significantly more used anti-diarrhoeal medication ( P = 0.029), complained of a high frequency of defaecation ( P = 0.005), experienced a longer time to the initiation of defaecation ( P = 0.049) and underwent pouchoscopy ( P = 0.003). Biofeedback appeared to improve the symptoms in 7 of 16 patients with a nonmechanical defaecatory difficulty. The most common findings on defaecating pouchography included residual barium of more than 33% after an attempted evacuation (46%, n = 24), slow evacuation (35%, n = 18) and mucosal irregularity (33%, n = 17). Correlation between radiological features and symptoms showed a statistically significant relationship between straining, anal pain, incontinence and urgency with patterns of anismus or pelvic floor descent or weakness seen on the defaecating pouchogram. Symptoms of incomplete evacuation, difficulty in the initiation of defaecation, high defaecatory frequency and abdominal pain were not correlated with the radiological features of the pouchogram. Conclusion Defaecating pouchography may be useful for identifying anismus and pelvic floor disorders in pouch patients who have symptoms of straining, anal pain or incontinence. In patients with a high frequency of defaecation and abdominal pain it does not provide clinically meaningful information. Patients who complain of straining, incontinence, anal pain or urgency and have anismus or pelvic floor disorders may benefit from behavioural therapy. [ABSTRACT FROM AUTHOR]

Objective The diagnostic accuracy of anorectal manometry (AM), which is necessary to diagnose functional defecatory disorders (FDD), is unknown. Using blinded analysis and standardised reporting of diagnostic accuracy, we evaluated whether AM could discriminate between asymptomatic controls and patients with functional constipation (FC). Design Derived line plots of anorectal pressure profiles during simulated defecation were independently analysed in random order by three expert observers blinded to health status in 85 women with FC and 85 age-matched asymptomatic healthy volunteers (HV). Using accepted criteria, these pressure profiles were characterised as normal (ie, increased rectal pressure coordinated with anal relaxation) or types I-IV dyssynergia. Interobserver agreement and diagnostic accuracy were determined. Results Blinded consensus-based assessment disclosed a normal pattern in 16/170 (9%) of all participants and only 11/85 (13%) HV. The combined frequency of dyssynergic patterns (I-IV) was very similar in FC (80/85 (94%)) and HV (74/85 (87%)). Type I dyssynergia ('paradoxical' contraction) was less prevalent in FC (17/85 (20%) than in HV (31/85 (36.5%), p=0.03). After statistical correction, only type IV dyssynergia was moderately useful for discriminating between FC (39/85 (46%)) and HV (17/85 (20%)) (p=0.001, positive predictive value=70.0%, positive likelihood ratio=2.3). Interobserver agreement was substantial or moderate for identifying a normal pattern, dyssynergia types I and IV, and FDD, and fair for types II and III. Conclusions While the interpretation of AM patterns is reproducible, nearly 90% of HV have a pattern that is currently regarded as 'abnormal' by AM. Hence, AM is of limited utility for distinguishing between FC and HV. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of the study was to determine if the strain phase of an MR defecography (MRD) protocol is redundant and can be eliminated without a loss of diagnostic information. Materials and methods: Institutional review board approval was obtained and the requirement for informed consent was waived. A retrospective single-center review of 80 MRD examinations (68 female, 12 male, mean age 55 years old) was conducted. Two radiologists blinded to patient information evaluated in consensus the strain and evacuation phases separately and in a random order. Each phase was assessed for the presence and degree of posterior compartment descent, cystocele, urethral hypermobility, uterovaginal prolapse, rectocele, rectal intussusception, and enterocele. The degree of pelvic floor descent was compared using a paired t test and McNemar's test was used to compare the proportion of abnormal findings. Results: The evacuation phase identified all abnormalities identified on the strain phase and also identified both additional and more pronounced abnormalities, including an additional 34 cystoceles, 20 cases of urethral hypermobility, 13 uterovaginal prolapses, 36 rectoceles, 5 rectal intussusceptions, and 6 enteroceles (all p < 0.02). The mean posterior compartment descent was 24.1 mm greater on the evacuation phase than the strain phase ( p < 0.0001). Conclusion: The strain phase is redundant and we propose that it can be eliminated from a routine MRD protocol. This will help streamline the examination, simplify patient instructions, and reduce both imaging and reporting time. [ABSTRACT FROM AUTHOR]

Aim Newer 5-hydroxytryptamine agonists, such as prucalopride, have been demonstrated to be effective in the short term for treatment of chronic constipation. To date, few studies have investigated their medium- and long-term effectiveness. Method An analysis was carried out of a prospectively maintained database of all patients started on prucalopride for chronic constipation between April 2011 and April 2014. Cleveland Clinic Constipation Score ( CCCS) questionnaires were administered before starting treatment with prucalopride and at the first follow-up visit to assess change in CCCS scores in 50 randomly selected patients. Results A total of 155 patients (median age: 47 years; seven men) were started on prucalopride in this period. Of these, 16 (10%) had slow-transit constipation, 31 (20%) had obstructive defaecation syndrome and 30 (19%) had a combination of both. Of these 155 patients, 78% patients were on three or more laxatives at the time of starting prucalopride. Patients were started on 1 mg or 2 mg according to their age. The median follow-up period was 24 (range: 4-40) months. At the first follow-up visit, 106 (68%) patients reported good symptomatic improvement, whereas the remainder had no response. Third of initial responders showed decreased efficacy after a median duration of 6 months and needed regular laxatives/irrigation. Of the 50 patients who filled in the CCCS questionnaires (15 patients were nonresponders), 32 (64%) reported improved scores with a median improvement of two points per criterion. Conclusion This study provides evidence that prolonged use of prucalopride is effective in achieving a sustained benefit in the majority of patients. [ABSTRACT FROM AUTHOR]

Purpose To evaluate effects of altering rectal contrast volume on defecatory effort during magnetic resonance defecography (MRD). Methods We assessed defecation qualitatively and quantitatively as a function of rectal distention (group A: 180 cc, n = 31; group B: 120 cc, n = 31). Quantitative evaluation comprised measuring rectal area on midline sagittal images pre- and post-defecation. Results Resting rectal area was significantly higher for group A than for group B (35.2 vs. 28.3 cm 2 , P < .0001). Post-defecation rectal area and change in area (pre- to post-defecation) were not significantly different. Subjective evaluation showed no significant difference. Conclusion Decreasing rectal gel volume from 180 to 120 cc did not compromise defecation performance during MRD. [ABSTRACT FROM AUTHOR]

Introduction: X-ray defecography is considered the gold standard for imaging pelvic floor pathology. However, it is limited by the capability to demonstrate only the posterior pelvic compartment, significant radiation exposure, and inconvenience. Dynamic transperineal ultrasound (DTP-US) can visualize all of three pelvic floor compartments, is free of radiation, and does not cause significant discomfort. The aim of this study was to evaluate the level of consistency between defecography (DEF) and DTP-US in the diagnosis of pelvic floor deformations. Methods: One hundred and five women (age 56 ± 11 years) suffering from constipation and fecal incontinence were clinically evaluated and further examined by DEF and DTP-US. The rate of diagnosis of pelvic floor hernias using the DTP-US was compared to that found on DEF. Results: The specificity for the diagnosis of rectoceles was of 82 % for mid-size rectocele and 98 % for large rectoceles, and the sensitivity was of 59 % for mid-size rectoceles and 50 % for larger rectoceles. The sensitivity for the detection of intussusceptions, enteroceles, and rectal prolapse were 82, 74, and 75 %, respectively. The specificity was 84 % for the detection of intussusception, 92 % for enteroceles, and 97 % for the diagnosis of rectal prolapse. Higher rates of DTP-US diagnosis were obtained when the intussuscepted rectum moved closer toward the ultrasound probe. Conclusions: The sensitivity of DTP-US was good to excellent and the specificity was high. The added value of this technique in exploring all the compartments of the pelvic floor as well as the perineal muscles makes DTP-US a preferred procedure. [ABSTRACT FROM AUTHOR]

Background: Defecography is a study to assess anorectal function during evacuation. Objective: To investigate the value of fluoroscopic defecography in directing diagnostic and therapeutic management in children with defecation disorders. Materials and methods: We reviewed all fluoroscopic defecography studies performed (2003-2009) in children with defecation problems and normal anorectal motility studies. Results were classified into three groups: (1) normal pelvic floor function; (2) pelvic floor dyssynergia, including incomplete relaxation of pelvic musculature, inconsistent change in anorectal angle and incomplete voluntary evacuation; (3) structural abnormality, including excessive pelvic floor descent with an intra-rectal intussusception, rectocele or rectal prolapse. Results: We included 18 patients (13 boys, median age 9.1 years). Indication for fluoroscopic defecography was chronic constipation in 56%, fecal incontinence in 22% and rectal prolapse in 22%. Defecography showed pelvic floor dyssynergia in 9 children (50%), a structural abnormality in 4 (22%) and normal pelvic floor function in 5 (28%). In 12 children (67%) the outcome of fluoroscopic defecography directly influenced therapeutic management. After defecography 4 children (22%) were referred for anorectal biofeedback treatment, 4 children (22%) for surgery, 2 children (11%) for additional MR defecography, and 1 child to the psychology department, and medication was changed in 1 child. In 6 children (33%) the result did not change the management. In 9 children (75%) the change of management was successful. Conclusions: Fluoroscopic defecography can be a useful tool in understanding the pathophysiology and it may provide information that impacts management of children with refractory defecation disorders. [ABSTRACT FROM AUTHOR]

These guidelines summarize the definitions, diagnostic criteria, differential diagnoses, and treatments of a group of benign disorders of anorectal function and/or structure. Disorders of function include defecation disorders, fecal incontinence, and proctalgia syndromes, whereas disorders of structure include anal fissure and hemorrhoids. Each section reviews the definitions, epidemiology and/or pathophysiology, diagnostic assessment, and treatment recommendations of each entity. These recommendations reflect a comprehensive search of all relevant topics of pertinent English language articles in PubMed, Ovid Medline, and the National Library of Medicine from 1966 to 2013 using appropriate terms for each subject. Recommendations for anal fissure and hemorrhoids lean heavily on adaptation from the American Society of Colon and Rectal Surgeons Practice Parameters from the most recent published guidelines in 2010 and 2011 and supplemented with subsequent publications through 2013. We used systematic reviews and meta-analyses when available, and this was supplemented by review of published clinical trials. [ABSTRACT FROM AUTHOR]

Background: Colorectal surgery is a budding subspecialty of paediatric surgery and typifies the advances in the management of surgical conditions in children. The colorectal burden in resource poor settings, though reported to be challenging, remains undocumented. The aim of the present study was to review the typical operative paediatric colorectal caseload in a single centre in sub-Saharan Africa. Materials and Methods: A retrospective review of the operative records of the division was conducted between 2009 and 2013. Data were obtained on the demography, diagnosis, procedure performed and type of anaesthesia used; entered into a computer using SPSS (IBM Corp; Armonk, NY) and analysed. Results: A total of 120 colorectal operations were performed in 90 patients with age ranging from 1 to 13 years. The major diagnoses were anorectal malformations (64.4%) and Hirschsprung disease (HD) (31.1%). The most often performed operations were colostomy (45.0%), posterior sagittal anorectoplasty (17.5%) and pull through (17.5%). The number of colorectal operations performed each year ranged from 12 in 2009 to 36 in 2012. A higher proportion of patients with anorectal malformations (46.6%) presented within the neonatal period compared with those with HD (17.9%), P = 0.005. The age at definitive surgery was less in patients with anorectal malformations compared to patients with HD (P = 0.003). Conclusions: Congenital malformations represent the bulk of the caseload in paediatric colorectal surgery in sub-Saharan Africa and patients typically present late; although patients with anorectal malformations present and are operated upon significantly earlier than those with HD. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Defecography is important diagnostic method for evaluating posterior pelvic floor disease. Defecography are done often for constipation, defecation difficulty, pain of anus complaint and rectocele, mucosal intusuception, enterocele and mucosal prolapsus is appeared. 54 patients who underwent defecography evaluated retrospectively between 1 January to 31 December 2012 at Bursa Military Hospital. Patients were evaluated with age, gender, admission complaints, previous surgeries, birth numbers and defecography findings retrospectively. 11 (20.4%) were male and 43 (79.6%) were female. The mean age of patients were 44.78 ± 13.77, duration of complaints of 8.08 ± 7.08 years (mean ± standard deviation), respectively. Patients had most commonly complaint of constipation (72.2%), and difficulty in defecation (68.5%). The most common signs was rectocele (74%), mucosal intusuception was the second (61%) and rectocele with mucosal intusuception was found in 51.8% of patients. 53.7% of the patients had a previous surgery history, gynecological surgery was the most common (38.8%) previous surgery history. The most common birth number was two with 42% and no birth with 14% of 43 female patients. Defecography is a safe, simple, minimally invasive and important diagnostic method with obtains valuable information about the dynamics of defecation, and allowing the male patients as well as female patients. Gender, gynecological, coloanal and anorectal surgery and history of normal birth leads to significant changes in posterior pelvic floor disorders and in defecography findings [ABSTRACT FROM AUTHOR]

The article provides information on the fecal incontinence condition in the U.S. It states that almost 18 million American adults have fecal incontinence, but the actual prevalence remains unknown since the condition is often undetected and unreported. It discusses the risk factors and main causes of fecal incontinence, as well the tools needed for assessing the severity and the surgical options like colostomy.

There are no clear recommended imaging guidelines for the assessment of patients presenting primarily with obstructed defecation syndrome and defecation difficulty. The gold standard has always been the defecating proctogram which may require a rather poorly tolerated extended technique involving high-radiation exposure in young women which includes cystography, vaginography, small bowel opacification, and occasional peritoneography. The development of dynamic magnetic resonance imaging has obviated many of these extended techniques and may be supplemented by novel ultrasonographic methods including dynamic transperineal sonography, real-time 3D translabial ultrasound and 3D dynamic echodefecography. Patients potentially suitable for surgical treatment display a multiplicity of pelvic floor and perineal soft-tissue anomalies where one pathology (such as rectocele or enterocele) are considered dominant. Despite the introduction of recent stapled and robotic technologies, there is a dual dialog concerning the functional outcome of these procedures. Imaging and surgical algorithms for these patients are provided. [ABSTRACT FROM AUTHOR]

The obstructed defecation syndrome is the main functional disorder of the posterior or ano-rectal pelvic floor compartment. Different mechanical and functional rectal disorders may cause this syndrome, including rectocele, rectal invagination, rectal prolapse, and pubo-rectalis muscle dyskinesia. Since pelvic floor muscles and fasciae act as a unique functional entity, dysfunctions of the posterior compartment are usually associated to variable dysfunctions of the anterior and middle urogenital compartments as well. Over 50% of postmenopause women are affected by severe symptoms due to pelvic floor disorders, with frequent need of surgical invasive treatments. Both diagnosis of the specific ano-rectal dysfunction and identification of all possible associated disorders are mandatory for an effective surgical or conservative treatment. Currently, dynamic MRI provides an excellent morphological and functional display of the pelvic floor like no other imaging modality. Pros and cons of posterior pelvic floor MRI, different evaluation techniques, reference lines and grading systems together with the main imaging findings will be discussed and illustrated. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background and purpose: Anorectal manometry is a suitable diagnostic method in children with chronic constipation and could provide useful information on the causes of constipation. This study was done to evaluate the therapeutic response of standard treatment and improve the diagnostic method via assessment of manometric parameters before and after the standard treatment. Materials and methods: In a randomized clinical trial, anorectal manometry was performed in 48 patients including 31 male (with the mean age of 6.8±1.08 years) with chronic constipation. The manometry parameters were compared before and after six months therapeutic period. Results: Forty eight children with chronic constipation underwent anorectal manometric testing. Basal anal pressure decreased in standard treatment (P<0.004). According to clinical symptoms, acceptable therapeutic response was achieved in 27 (75%) patients. Severe changes in sphincter relaxation were seen at one second after rectal dilatation phase. But no significant differences were seen in Amplitude and duration of relaxation in volumes higher than 30cc. Conclusion: Standard treatment had no long term effect on Duration of Relaxation, however, it could play a role in improving the status of patient by influencing Amplitude of relaxation. More changes were seen at one second after rectal dilatation phase, hence, the length of manometry procedure can be shortened. [ABSTRACT FROM AUTHOR]

Congenital colon pouch syndrome, is an infrequent clinical condition in which the colon is totally o partially replaced by a cystic dilatation, and is associated with an anorectal malformation; which may be a urinary tract fistula, a vaginal or vestibule fistula, or a cul-de-sac. We present a rare variant of the anorrectal malformation, with two cases of colon pouch types II and III respectively. The diagnosis was suspected in a plain X-ray and on a distal colostogram. It was confirmed during surgery. The controversial aspects of surgical options are discussed, and emphasis is made on the importance of the follow-up of patients with anorectal malformations, including the need for bowel rehabilitation. [ABSTRACT FROM AUTHOR]

Background Guidelines recommend instruction and motivation during anorectal manometry; however, its impact on findings has not been reported. This study assessed the effects of standard versus enhanced instruction and verbal feedback on the results of anorectal manometry. Methods High-resolution manometry was performed by a solid-state catheter with 10 circumferential sensors at 6 mm separation across the anal canal and two rectal sensors. Measurements were acquired first with standard instruction and then with enhanced instruction and verbal feedback. On both occasions, squeeze pressure and duration during three voluntary contractions and intra-rectal pressure and recto-anal pressure gradient (RAPG) during three attempts at simulated defecation were assessed. Key Results A total of 70 consecutive patients (54 female; age 25-82 years) referred for investigation of fecal incontinence ( n = 31), constipation, and related disorders of defecation ( n = 39) were studied. Enhanced instruction and verbal feedback increased maximum squeeze pressure (Δ10 ± 28.5 mmHg; P < 0.0038) and duration of contraction (Δ3 ± 4 s; P < 0.0001). During simulated defecation, it increased intra-rectal pressure (Δ12 ± 14 mmHg; P < 0.003) and RAPG (Δ11 ± 20 mmHg; P < 0.0001). Using standard diagnostic criteria, the intervention changed manometric findings from locally validated 'pathologic' to 'normal' values in 14/31 patients with incontinence and 12/39 with disorders of defecation. Conclusions & Inferences Enhanced instruction and verbal feedback significantly improved voluntary anorectal functions and resulted in a clinically relevant change of manometric diagnosis in some patients. Effective explanation of procedures and motivation during manometry is required to ensure consistent results and to provide an accurate representation of patient ability to retain continence and evacuate stool. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to test our hypothesis that the reason why imaging is of little assistance in diagnosing 'constipation' causes may be related to the high sensitivity of internal anorectal flow resistance in defecation to small changes in geometry. We applied a mathematical model to describe the effects on flow mechanics of observed changes in the shape of the rectum and anus during defecation. Methods: Three groups of patients were studied with video proctograms. Group 1 comprised 4 patients with normal defecation studied with video proctography or magnetic resonance imaging (MRI). Group 2 comprised 8 patients with fecal incontinence, studied by video X-ray electromyography. Group 3 comprised 8 patients with constipation evaluated by video MRI. Results: Three muscle vectors open the anorectal angle prior to defecation, causing the anorectal luminal diameter to increase to approximately twice its resting size. These vectors are forwards (anterior wall), backwards and downwards (posterior wall). Resistance to passage of a fecal bolus through the anorectum is determined by viscous friction against the anorectal wall and by the energy required to deform the bolus as it flows. The observed changes in anorectal geometry serve to reduce both the viscous friction in the anus and the deformation of the bolus, which reduces the force required to facilitate its passage through the anus. For example, if the effective diameter of the anus is doubled during defecation, the frictional resistance is reduced by a factor of 8. Conclusions: The sensitivity of flow resistance to geometry explains why MRI or computed tomography (CT) scans taken during defecation are not often helpful in diagnosing causation. Small changes in geometry can have a disproportionate affect on flow resistance. Combining accurate directional measurements during dynamic MRI or CT scans taken during defecation with observations of bolus deformation, and if possible, simultaneous anorectal manometry, may provide clinically helpful insights on patients with anorectal evacuation disorders. [ABSTRACT FROM AUTHOR]

The majority of proctological diseases can be defined by a structured evaluation of the symptoms and a physical examination. Magnetic resonance imaging (MRI) and anal endosonography can detect complex anal fistulas with a high accuracy but MRI should be preferred because of its objective visualization. Functional anorectal disorders are multifactorial and show morphological and functional irregularities in different compartments of the pelvic floor which is why MR defecography is now one of the most important methods in diagnostic algorithms. Interpreting the results of anal endosonography, anal manometry and neurophysiological testing is highly demanding because of large interindividual variability. Scores are used for objective measurement of symptom severity and quality of life. In clinical practice, well validated scores evaluated in large patient groups with predetermined circumstances are needed. Bringing together morphological results with scores based on subjective perception is required to optimize diagnostics and therapy evaluation in proctology. [ABSTRACT FROM AUTHOR]

Background and purpose: Todays one of the most common anorectal problems is hemorrhoid.Minor symptom of disease can be treated by medical treatment but at high grade disease we should consider surgery. Although conventional surgery is standard operation for hemorrhoid, it is associated with some complication. Many technique were designed to overcome these problems. One of these procedures is Ligasure hemorrhoidectomy that this study was done to compare it with conventional hemorrhoidectomy. Materials and methods: This was a randomized cilinical trial study of 60 patients with thirddegree or four-degree hemorrhoid that was divided into two groups randomly. Operative time, bleeding, postoperative pain, rate of wound healing were recorded. Results: we randomized 60 patients, 30 to Ligasure and 30 to conventional. There were no difference in patients demographic datas. Operative time, bleeding, pain at second postoperative day in Ligasure group was less than the conventional. There was no difference in rate of healing, pain at first day postoperation and complications. Conclusion: Ligasure hemorrhoidectomy is a safe and feasible procedure and in comparison with conventional hemorrhoidectomy cause more pain control and satisfaction. [ABSTRACT FROM AUTHOR]

Congenital anal web is a rare form of anorectal malformation. In cases of delayed diagnosis, patients can present with signs ranging from mild constipation to complete bowel obstruction. The diagnosis is made by thorough anorectal inspection and a digital rectal exam. We present the case of a 9-month-old boy with Down's syndrome with chronic constipation secondary to an anal web. To our best knowledge, this is the first report of an anal web in a patient with Down's syndrome presenting with severe chronic constipation. [ABSTRACT FROM AUTHOR]

Background Recto-anal inhibitory reflex (RAIR) is an integral part of normal defecation. The physiologic characteristics of RAIR along anal length and anterior-posterior axis are unknown. The aim of this study was to perform topographic and vector-graphic evaluation of RAIR along anal canal using high definition manometry (HDM), and examine the role of various muscle components. Methods Anorectal topography was assessed in 10 healthy volunteers using HDM probe with 256 sensors. Recto-anal inhibitory reflex data were analyzed every mm along the length of anal canal for topographic, baseline, residual, and plateau pressures during five mean volumes of balloon inflation (15 cc, 40 cc, 71 cc, 101 cc, 177 cc), and in 3D by dividing anal canal into 4 × 2.1 mm grids. Key Results Relaxation pressure progressively increases along anal canal with increasing balloon volume up to 71 cc and thereafter plateaus. In 3D, RAIR is maximally seen at the middle and upper portions of anal canal (levels 1.2-3.2 cm) and posteriorly. Peak residual pressure was seen at proximal anal canal. Conclusions & Inferences Recto-anal inhibitory reflex is characterized by differential anal relaxation along anterior-posterior axis, longitudinally along the length of anal canal, and it depends on the rectal distention volume. It is maximally seen at internal anal sphincter pressure zone. Multidimensional analyses indicate that external anal sphincter provides bulk of anal residual pressure. Our findings emphasize importance of sensor location and orientation; as anterior and more distal location may miss RAIR. [ABSTRACT FROM AUTHOR]

Introduction. Defecography is a study that provides functional and structural information on the anorectal region. Patients with defecatory disorders, such as fecal incontinence and constipation, are difficult to diagnose and treat. Defecography may help in evaluating such patients, both in detecting anatomical abnormalities and possible causes of such disorders and as an anatomical guide if surgical correction proves necessary.1,2 Purpose. The purpose of this article is to review the anatomy of the pelvic floor and the physiology of defecation, describe the technique of defecography and radiological diagnosis of defecatory disorders and prolapse of the pelvic organs, and finally to report the experience of Hospital San Jose Tec de Monterrey with this radiological technique. Material and methods. Three hundred and thirty-one defecatory studies performed in patients at Hospital San Jose Tec de Monterrey, from 1996 to 2010, were retrospectively analyzed. Two hundred and ninety-one women and 40 men were included, with ages ranging from 4 to 80 years (average age 41.03 years). Aperture of the anal canal, relaxation of the puborectalis muscle, evacuation of contrast medium, pelvic floor descent, mucosal procidentia, and rectal prolapse were evaluated. Results. All the defecographies revealed some abnormality. Two hundred and eighty-eight anterior rectoceles, 21 posterior rectoceles, as well as 140 cases of invagination, 99 of pelvic floor descent, 40 of enterocele, and 37 of mucosal procidentia and prolapse were identified, and other anomalies such as 1 ulcer (0.15%), 1 megarectum (0.15%), and 1 incontinence (0.15%). Conclusion. Today defecography plays a very important role in evaluation of patients with constipation and has influenced the choice of different treatment options. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to compare the diagnostic efficacy of dynamic MR defecography (MR-D) with entero-colpo-cysto-defecography (ECCD) in the assessment of midline pelvic floor hernias (MPH) in female pelvic floor disorders. Methods: From August 2004 to August 2010, 3,006 female patients who required ECCD for the evaluation of pelvic floor disorders were enrolled in this study. All the 1,160 patients with ECCD findings of MPH were asked to undergo MR-D; 1,142 accepted to undergo MR-D and constituted the object of analysis. This study was approved by the Institutional Ethical Committee. All the patients gave their written informed consent to take part in the study. Results: Overall, the prevalence of MPH at ECCD was higher if compared with that at MR-D. Concerning the hernia content, there were significantly more enteroceles and sigmoidoceles on ECCD than on MR-D, whereas, in relation to the hernia development modalities, the prevalence of elytroceles, edroceles, and Douglas' hernias at ECCD was significantly higher than that at MR-D. In spite of a 100% specificity, the sensibility of MR-D in the detection of an omentocele, sigmoidocele, and enterocele was, respectively, 95%, 82%, and 65%, showing an inferior diagnostic capacity if compared with that of ECCD. Conclusion: MR-D shows lower sensitivity than ECCD in the detection of MPH development. The less-invasive MR-D may have a role in a better evaluation of the entire pelvic anatomy and pelvic organ interaction especially in patients with multicompartmental defects, planned for surgery. [ABSTRACT FROM AUTHOR]

Neurofibromatosis type 1, also known as von Recklinghausen disease, is an autosomal dominant disorder with an incidence of 1 per 4000. Neurofibromas are benign, heterogeneous tumors arising from the connective tissue of peripheral nerve sheaths, especially the endoneurium. Visceral involvement in disseminated neurofibromatosis is rare. Neurofibroma occurs most frequently in the stomach and jejunum, but the colon and anorectal canal may also be involved. Gastrointestinal neurofibromas may lead to bleeding, obstruction, intussusception, protein-losing enteropathy and bowel perforation. We present a case of diffuse involvement of the anorectal area by a huge neurofibroma, with pelvic pain, watery diarrhea and urgency. [ABSTRACT FROM AUTHOR]

Purpose: To determine the degree of stress in parents of children operated for intermediate anorectal malformations, and their quality of life (QOL) at follow-up.Methods: Forty-two of the 166 children who had undergone a sacroperineal pullthrough operation for an intermediate type of anorectal malformation, between 1996 and 2005, in the department of paediatric surgery at Christian Medical College, Vellore, responded to follow-up. The psychosocial well-being of the parents and the QOL of the children were assessed by an independent observer.Results: The main factor which aggravated the stress and caused dissatisfaction with the final outcome was fecal soiling. Mothers bore the brunt of the care of these children, with some help from the fathers and grandparents. The QOL was also significantly affected by soiling, and improvement in soiling resulted in a dramatic improvement in the QOL.Conclusion: Managing fecal soiling aggressively in the child with anorectal malformation, and providing social support to the family, are crucial for achieving a better QOL in these children and their families. [ABSTRACT FROM AUTHOR]

Proctalgia fugax (PF) is a benign anorectal condition which has been described in the literature since the nineteenth century commonly presenting to general surgeons. There is little high level evidence on the subject and its therapeutic modalities. We aimed through this systematic literature review to outline the definition and diagnostic criteria of this condition, the aetiology and differential diagnoses and describe the different treatment modalities that have been attempted and their success. A literature search of Google Scholar™ and Medline using Pubmed as the search engine was used to identify all studies directly related to the definition, aetiology and treatment options for this condition (latest at 12 August 2008) was performed. The search produced 61 references with three others obtained from the references of these papers. The prevalence of PF in the general population ranges from 4% to 18%. The diagnosis is based on the presence of characteristic symptoms as defined by Rome III guidelines and physical examination. The mainstay of treatment is reassurance and careful counselling with evidence in the literature for warm baths, topical treatment with glyceryl trinitrate or diltiazem and salbutamol inhalation. In persistent cases, local anaesthetic blocks, clonidine or Botox injections can be considered after clarification of risk and benefit. Based on this we suggest that diagnosis should be made through exclusion of common organic causes such as haemorrhoids, anal fissure or anorectal carcinoma and on the fulfilment of Rome III criteria. The main treatment for this benign condition remains reassurance and topical treatment. [ABSTRACT FROM AUTHOR]

Aims. To verify the correlation between anorectal function and psychological conditions of depression/anxiety in patients with functional constipation. The aim of this study is to explore why people with depression/anxiety have higher incidence of functional constipation and recommend innovative interventions to advance patient care of functional constipation. Design. A prospective correlational design. Methods. Anorectal manometry was performed on functional constipation patients ( n = 70) through the Medtronic Synectics PC Polygraf, while the psychological condition was tested by Self-Rating Anxiety Scale and Self-Rating Depression Scale. Twenty normal controls were also studied. Results. Compared with controls, (1) functional constipation patients displayed higher squeezing pressure, defaecation thresholds and maximal volume of tolerance ( p < 0·01), and there was no significant difference in anorectal resting pressure, defaecating pressure, minimum relaxation volume and first sensation ( p > 0·05). (2) Functional constipation patients showed higher depression/anxiety scores ( p < 0·01). (3) The anorectal squeezing pressure was negatively correlated with anxiety and depression scores, while the first sensation and maximal volume of tolerance was positively correlated with depression score ( p < 0·05). Conclusions. Abnormal anorectal function correlates to depression/anxiety levels indicating that depression/anxiety may contributes to functional constipation. The possible pathology is via brain-gut axis. Relevance to clinical practice. The study indicates that nurses should pay attention to the patients’ psychological needs, especially to those interested in seeing the physician and doing unnecessary examinations repeatedly to find any organic disease. Integrated nursing intervention should be applied to improve patients’ psychological adaptation and boost the functional constipation therapeutic effect. [ABSTRACT FROM AUTHOR]

Introduction Evacuation proctography (EP) is considered to be the gold standard investigation for the diagnosis of posterior compartment prolapse. 3D transperineal ultrasound (3DTPUS) imaging of the pelvic floor is a noninvasive investigation for detection of pelvic floor abnormalities. This study compared EP with 3DTPUS in diagnosing posterior compartment prolapse. Method In a prospective observational study, patients with symptoms related to posterior compartment prolapse participated in a standardized interview, clinical examination, 3DTPUS and EP. Both examinations were analysed separately by two experienced investigators, blinded against the clinical data and against the results of the other imaging technique. After the examinations, all patients were asked to fill out a standardized questionnaire concerning their subjective experience. Results Between 2005 and 2007, 75 patients were included with a median age of 59 years (range 22–83). The Cohen’s Kappa Index for enterocole was 0.65 (good) and for rectocele it was 0.55 (moderate). The level of correlation for intussusception was fair (κ = 0.21). Conclusion This study showed moderate to good agreement between 3DTPUS and EP for detecting enterocele and rectocele. [ABSTRACT FROM AUTHOR]

Introduction: In the literature, data on the effects of gender and age on the pressure data of anorectal manometry differ. Possible reasons are investigation of only small numbers of healthy people and comparison of only 2 groups with large age differences. In addition, data about the influence of gender or age on anorectal sensation are sparse. Therefore, the aim of the present study was to determine the influence of gender and age on anorectal manometry in a large healthy female and male cohort spanning a great age range. Methods: Anorectal manometry was performed in 72 women and 74 men with a median age of 64 years in both groups (ranges: women 22–90 years; men 23–88 years). We determined mean anal resting and squeeze pressure as well as minimal rectal balloon volume for perception and for urge/desire to defecate. The Mann-Whitney U test was used to analyze for gender differences, regression analysis to search for age influences. Results: Squeeze pressure (p = 0.007) and perception threshold (p < 0.001) are significantly lower in females, while the mean resting pressure and urge threshold are similar in females and males. Mean resting pressure (women p < 0.0001; men p = 0.03) and mean squeeze pressure decrease (women p < 0.0001; men p = 0.004) with age. An age-related increase in sensory thresholds (= decreased rectal sensitivity) is only seen in females (perception threshold p = 0.01; urge threshold p = 0.04). Conclusion: Most of the parameters measured by anorectal manometry (anal canal pressure, sensory thresholds) are influenced by gender and age. Therefore, the results of anorectal manometry must be interpreted in relation to sex- and age-adapted normal values. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Anorectal manometry provides an objective assessment of anal sphincter pressure and rectal sensitivity and anorectal reflexes in response to distension. However, its clinical utility is hampered by a lack of standardized protocols and normative data from healthy subjects. Previous studies have used water-perfused systems in normal subjects, but some adopted a rapid pull-through technique; others did not evaluate rectal sensations and others did not carefully exclude patients with functional bowel disorders. Objective To evaluate anorectal function in healthy adults without functional bowel disorders, using a water-perfused system with the stationary technique in order to obtain normative values for anorectal manometry. Method Fifty-two healthy volunteers with no Rome II diagnostic criteria for functional bowel disorders, including only nulliparous women, underwent anorectal manometry with a water-perfused system, according to a standardized protocol. Results Maximum squeeze pressure of the anal sphincter as well as the area under the pressure-time curve during squeeze was significantly lower in women than men ( P < 0.01), while sphincter length, resting pressure, volume thresholds for reflex inhibitory recto-anal and rectal sensations were similar. Conclusions This study describes a protocol for stationary anorectal manometry using a water-perfused system, and a method for analysing the various parameters obtained during the procedure, as recently suggested in the international literature. It supplies normative data obtained in a population of healthy subjects including nulliparous women, with no functional bowel disorders. [ABSTRACT FROM AUTHOR]

The author reflects on the need to find a simple scoring system for assessing fecal incontinence (FI). Topics discussed include the impact of the condition on a person's quality of life (QOL), the validated methods used to score FI such as the Jorge-Wexner score at Cleveland Clinic, and the correlations between the severity of FI and its impact on QOL.

The aim of this study was to demonstrate the distribution of defecographic pelvic floor abnormalities in constipated female patients and to correlate these dysfunctions with the mode of delivery. Two hundred and fifty-five female patients who underwent defecography for constipation from 2001 to 2008 were reviewed and pelvic floor abnormalities were assessed. The patients were divided into three groups: group I had 50 nulliparous women, mean age 40.2 (±15.3), group II had 165 vaginally parous women, mean age 57 (±13.3), and group III had 40 patients delivered by cesarean section, mean age 50.6 (±11.9). Significant rectocele was identified in group I (36%), group II (35.8%), and group III (20%) without any statistically significant differences among the groups ( p > 0.05). Intussusception was identified in group I (48%), group II (70.3%), and in group III (67.5%; p = 0.014). Intussusception associated with significant rectocele was more common in vaginally parous patients ( p = 0.043). Abnormalities on puborectalis relaxation associated or not associated with rectocele were similar among the groups ( p = 0.47). Vaginally parous patients had more abnormal exams as compared to other patients ( p = 0.005). Significant rectocele was identified in (39%) patients with age ≥50 years and in (26.3%) patients with age <50 years ( p = 0.03). There was no specific correlation between distribution of pelvic floor disorders and mode of delivery in this study. Patients of age greater than 50 years had a higher incidence of significant rectocele. [ABSTRACT FROM AUTHOR]

The objective of the study is to assess the efficacy of vital bulbocavernosus graft transposition in the treatment of rectovaginal fistula. From March 2003 to October 2007, nine consecutive patients diagnosed with rectovaginal fistula were refereed to our institute. All patients were treated using an interposing vital bulbocavernosus graft between rectum and vagina. Median patient age was 33 years (range, 19–61) and seven of the nine patients had undergone between one and six fistula repair sessions prior to this grafting procedure. The etiology included congenital in three, surgery injury in four, obstetric in one, and radiation in one. No wound infections or abscesses occurred postoperatively, and the in-hospital mortality rate was zero. No recurrence was reported during the follow-up period and all patients had normal fecal continence. Only one patient had mild dyspareunia and no further surgical treatment needed. Both simple and complex rectovaginal fistula can be reliably repaired using a bulbocavernosus graft. [ABSTRACT FROM AUTHOR]

Study design:Intra-rater reliability study, cross-sectional design.Objectives:To report on the intra-rater agreement of the anorectal examinations and classification of injury severity in children with spinal cord injury (SCI).Setting:Two, non-profit children's hospitals specializing in pediatric SCI.Methods:180 subjects had at least two trials of the anorectal examinations as defined by the International Standards for Neurological Classification of Spinal Cord Injury. Intraclass correlation coefficients (ICC) and 95% confidence intervals (CI) were used to evaluate the agreement. ICC>0.90=high agreement; ICC between 0.75–0.89=moderate agreement; ICC<0.75=poor agreement.Results:When evaluated for the entire sample, agreement was moderate-high for anal sensation and contraction and injury classification. When evaluated as a function of age at examination and type of injury, agreement for anal sensation was poor for subjects with tetraplegia in the 12–15-year age group (ICC=0.56) and 16–21-year age group (ICC=0.70) and for subjects with paraplegia in the 6–11-year age group (ICC=0.69). Agreement for anal contraction was moderate for subjects with tetraplegia in the 16–21-year age group (ICC=0.81) and subjects with paraplegia in the 12–15-year age group (ICC=0.78) and poor for subjects with paraplegia in the 6–11-year age group (ICC=0.67). Agreement for injury classification was poor for subjects with tetraplegia in the 12–15-year group (ICC=0.56) and 16–21-year group (ICC=0.74) and paraplegia in the 6–11-year group (ICC=0.11) and 12–15-year group (ICC=0.63). Anorectal responses had high agreement in subjects with tetraplegia in the 6–11-year group and moderate to high agreement in subjects with paraplegia in the 16–21-year group.Conclusion:The data do not fully support the use of anorectal examination in children. Further work is warranted to establish the validity of anorectal examination. [ABSTRACT FROM AUTHOR]