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PubMed1994

Evacuation proctography (defecography): an aid to the investigation of pelvic floor disorders.

Patients with pelvic floor disorders frequently have associated anorectal dysfunction, which can be evaluated by a variety of laboratory tests. Evacuation proctography (defecography) documents the process of rectal evacuation and therefore demonstrates disorders of defecation, particularly those of an obstructive nature. It provides objective information about rectocele size and emptying and demonstrates coexistent enteroceles, many of which are missed on physical examination. This radiographic technique is the method of choice for recognizing rectal intussusception, the mechanism by which rectal prolapse occurs. Proctography suggests the diagnosis of spastic pelvic floor (anismus), a disorder amenable to biofeedback therapy. Proctography has limited application in anal incontinence unless there are associated obstructive symptoms. Evaluation of bladder dysfunction is aided by concomitant cystography. Gynecologists managing pelvic floor disorders should assess coexistent anorectal dysfunction, as undiagnosed enteroceles and disorders of defecation are an important cause of persistent or recurrent symptoms following pelvic floor repair. A comprehensive interdisciplinary approach to pelvic floor disorders is recommended.

Anal Canal↗
PubMed1993

Defecography: principles of technique and interpretation.

After description of the performance, physiology and normal findings of defecography, the main pathology is discussed as intra-anal rectal intussusception, extra-anal rectal intussusception, mucosal prolapse, rectocele, descending perineum syndrome, spastic pelvic floor syndrome and the solitary rectal ulcer syndrome. Finally, the radiation dose and pitfalls are reported.

Defecation↗
PubMed1993

[National working team report on defecography].

A questionnaire concerning defecography was submitted to 5 national experts in order to: 1) quantify the demand and 2) develop a consensus report. The demand is currently 2-8 exams week and the most frequent indication (70%) is obstructed defection, with/without constipation. The highest discriminatory capabilities was exhibited by the following variables: a) the anorectal angle (ARA) on straining and b) the distance from the pubococcygeal line (PCL) on squeezing (101.2 degrees +/- 15 vs. 120.6 degrees +/- 13, p < 0.05 and 27.4 mm +/- 15 vs. 2.4 mm +/- 7, p = 0.005, respectively) in chronically constipated patients (mean age: 60 years) when compared to the control group; and c) PCL on squeezing and at rest (35.5 mm +/- 20 vs. 2.4 mm +/- 7, p = 0.005 and 38.9 mm +/- 18 vs 18.4 mm +/- 17, p < 0.05, respectively) in patients with severe incontinence with respect to healthy subjects. While sensitivity and positive predictive values of the test were highest (97 and 98% respectively) for rectocele, specificity ranked first (92%) in anal gaping.

Defecation↗
PubMed1993

[Multivariate analysis of clinical signs, parameters of anorectal manometry, defecography, transit time of radiopaque markers in 76 patients complaining of fecal incontinence].

The aim of this study was to evaluate clinical symptoms, disease past-history, and parameters of anorectal manometry, defecography, and radiopaque pellet transit time in anal incontinence by multivariate analysis. We studied 76 patients, 68 women and 8 men, who complained of anal incontinence, excluding that due to obstetrical lesions. All patients were asked to complete a standard questionnaire. Results indicated that: a) hemorrhoidectomy, hysterectomy, and cholecystectomy appeared to play a role, b) daily incontinence for air or liquid stools is more frequent after hemorrhoidectomy, c) decreased resting pressure of the upper part of the anal canal was observed mainly after hysterectomy, d) decreased resting pressure of the upper part of the anal canal could be a factor of poor prognosis after treatment, e) anal incontinence in men was secondary to traumatic lesions of the anal sphincter in 7 of 8 cases.

Adult↗
PubMedDate not supplied

[The 3rd national workshop on defecography: the functional radiology of (neo) rectal ampullae (ileal reservoir, colo-anal anastomosis, continent perineal colostomy)].

A survey was made in 13 Italian centers with a questionnaire concerning the (a) indications, (b) postoperative complications, (c) functional results and (d) diagnostic imaging modalities related to the making of an ileal or colonic (neo) rectum. Ulcerative colitis (100%), familial polyposis (61.5%) and Crohn's disease (15.3%) were the most common indications for an ileal pouch; rectal cancer (7.96%), chronic inflammatory diseases (15.3%), diverticulosis, rectal prolapse, redundant colon and imperforate anus (7.6% each) were the most common indications for a colonic pouch. Postoperative complications included pelvic abscess (14%), sinus tract/dehiscence (10%) and bowel obstruction (9%). When compared with the S and W variants, the J-shaped ileoanal pouch proved superior because urgency and fecal retention rates were lower (18.4% vs. 44.4% and 23% vs. 28.6%, p < 0.01 and p < 0.05, respectively), despite slightly more frequent staining episodes (15.8% vs. 11.1%; p < 0.05). As for colonic ampullae, fecal retention and provoked evacuation were more frequent in the J pouch and after gracileplasty; urgency and incontinence in the straight colo-anal anastomosis (33.3% vs. 22.2% and 41.6% vs. 33.3%, respectively). The functional outcome was assessed by anal endosonography (available in 4/13 centers), defecography and anorectal manometry. Abnormal findings included: (a) reduced capacity, barium leakage, anal gaping, sphincter damage (urgency and incontinence); (b) barium retention, pouch dilatation, split evacuation, knobs and strictures (fecal retention).

Defecation↗
PubMedDate not supplied

Defecation disorders and the role of defecography.

This continuing education article discusses abnormalities of defecation and the physical mechanisms by which these abnormalities occur. The article also describes the role of defecography and other imaging techniques used to diagnose abnormalities of defecation.

Anal Canal↗
PubMed2000

Intraobserver and interobserver measurements of the anorectal angle and perineal descent in defecography.

PURPOSE: Anorectal angle and perineal descent can be measured either by drawing a line defined by the impression of the puborectalis muscle and the tangential of the posterior rectal wall (Method A) or by drawing a straight line at the level of the posterior rectal wall parallel to the central longitudinal axis of the rectum (Method B). The aim of this study was to assess the reproducibility of measuring anorectal angle and perineal descent by two different methods according to intraobserver and interobserver measurement and to evaluate which method yields more consistent results. METHODS: Five physicians who have had an average of 1.3 years (range, 6 months to 1.5 years) experience in defecographic measurement drew both lines on 63 randomly selected defecographic films and measured anorectal angle and perineal descent by the two methods. The defecographic parameters were measured twice by each observer during a three-week interval. To avoid potential bias, one physician who did not participate in either measurement of perineal descent or anorectal angle performed all data collection. Intraobserver and interobserver agreement was quantified using Shrout and Fleiss intraclass correlation coefficients. RESULTS: The mean and range of intraclass correlation coefficients for intraobserver agreement of measuring anorectal angle and perineal descent by Method A were 0.71 (0.6-0.78) and 0.89 (0.74-0.97), respectively, whereas with Method B the coefficients were 0.81 (0.73-0.89) and 0.93 (0.89-0.99), respectively. Regarding the interobserver agreement of the five observers, the mean coefficients for measurement of both anorectal angle and perineal descent by both methods showed similar agreement levels (0.88 and 0.98 by Method A and 0.89 and 0.97 by Method B). The mean (+/- standard deviation) values of anorectal angle and perineal descent found by Method B were significantly larger than those found by Method A (103.3 degrees +/- 19.6 and 6.56+/-3.20 cm and 91.1 degrees +/- 25.6 and 5.64+/-3.42 cm, respectively; P<0.001). CONCLUSION: Intraobserver and interobserver intraclass correlation coefficients of anorectal angle and perineal descent, which were measured by both methods, were more than 0.60, indicating that both methods are reliable and consistent for measurement of anorectal angle and perineal descent. However, centers should consistently use the same line for measurement of anorectal angle and perineal descent because of the statistically significant differences between the two methods and the possibility of inconsistent results.

Adult↗
PubMed2001

[Diagnostic value of defecography].

The aim of this study was to assess the importance of defecatography in the diagnosis of lower chronic constipation (4) or rectal type (12), principally in those patients on whom other diagnostic methods had not produced supportive data. Over a 64 month period, 65 patients who had consulted because of chronic constipation, were studied; they were suffering from low bowel symptoms like difficulty in the evacuation of the rectum. The average age was 48 and mostly female. All of them were asked to prepare the same mixture for the defecatory study, using the same type of contrast material and study technique. In most of the cases correlated functional elements were found, while very few cases resulting from just organic causes were found, and only one without functional or organic reason was found. Our results were as follows. 1) Insufficient laxity of the pubo-rectal beam related to forward or backward rectocele or lowering of the increased pelvic floor, a fact that was found in 19 patients (29.23%). 2) Inadequate laxity of the pubo rectal beam in 12 patients (18.46%). 3) Paradoxical contraction of the pubo rectal beam related to forward rectocele or lowering of the increased pelvic floor, in 11 patients (16.92%). 4) Lowering of the increased pelvic floor, related to forward or backward rectocele in 8 patients (12.30%). 5) Paradoxical contraction of the pubo rectal beam in 7 patients (10.76%). 6) Forward or backward rectocele in 3 patients (4.61%). 7) Lowering of the increased pelvic floor in 2 patients (3.07%). 8) Rectal intususception in 1 patient (1.53%). 9) Average study in 1 patient (1.53%). Therefore, the defecatography is a very useful method of study to appraise constipation with anorectoperineal symptoms, as it allows us to diagnose organic and functional problems in the area (6). Likewise, the importance of pre and post surgical tests, both therapeutic and reconstructive must be underlined.

Adult↗
PubMed1991

The reproducibility of measuring the anorectal angle in defecography.

Dynamic proctography is a radiographic procedure that has become widely used in the evaluation of pelvic floor function. The anorectal angle (ARA) is one parameter which is usually quantified during this examination. To determine the accuracy with which this measurement can be made, three physicians independently measured the resting and squeezing ARAs of 22 women. The coefficient of variation and the kappa statistic were used to describe the degree of agreement among the three examiners. These analyses revealed poor agreement among examiners for all 22 patients taken as individuals, (kappa less than or equal to 0.40; mean coefficient of variation at rest = 18 percent; mean coefficient during squeezing = 21 percent). These results suggest that measurements of ARAs will vary among examiners for any particular patient, even though individual examiners may demonstrate consistency in recording ARA data. There is wide interobserver variation in the measurement of the ARA from lateral radiographs, making quantification an exercise of only limited clinical value.

Adult↗
PubMed1994

Dynamic rectal examination (defecography).

Dynamic rectal examination (DRE), first described in 1952, is becoming more widely used in the dynamic evaluation of pelvic floor and anorectal motility disorders. It is a minimally invasive investigation which is well tolerated by patients and provides information about the anosphincteric, puborectal and levator muscle in addition to insight in rectal function and structure. DRE is the only investigation of anorectal function that can give detailed anatomical information such as the presence of a rectocele, an enterocele and an intussusception. DRE should be performed in a quiet environment with a minimum number of investigators present. Any technique which attempts to study the defecatory mechanism must be a compromise since the patient is aware of being studied. In order to defecate on command the radiologist must make the patient comfortable before starting the investigative procedures to avoid any possible psychological inhibition. We have not encountered any failures in this regard. The relative value of the radiological findings with respect to symptoms and complaints is insufficiently known. This has been the main incentive to design carefully and carry out a large prospective critical evaluation of various aspects of DRE in particular the correlation with objective findings and symptoms. Moreover an assessment has been made of its overall clinical utility (Wiersma, 1994). It is very likely that DRE is both investigator- and technique-dependent. To ensure that the study is as physiological as possible the contrast medium used to fill the rectum needs to be semi-solid and malleable equivalent in consistency to a normal faecal bolus. For proper anatomical studies in females vaginal opacification is mandatory. The acceptance of vaginal contrast was good. Only 4% of the female patients preferred not to have the vaginal application of contrast. The technique of DRE when performed with small bowel and vaginal opacification provides a sensitive and objective method of detecting enteroceles. A substantial number of female patients related the onset of their complaints to hysterectomy. In female patients with constipation there was a significantly higher incidence of enteroceles in patients with a hysterectomy compared to the group of females without hysterectomy. Because of these findings a series of pre- and postoperative DREs in hysterectomy patients are on their way in our institute. Unlike a rectocele which is usually most obvious during defecation, enteroceles are sometimes appreciated only with repeated straining after evacuation.(ABSTRACT TRUNCATED AT 400 WORDS)

Anal Canal↗
PubMed1988

Diagnostic anorectal functional studies. Manometry, sphincter electromyography, and defecography.

Anorectal manometric and electromyographic studies assess anorectal and pelvic floor neuromuscular disorders and can help in the diagnosis and management of incontinence, prolapse, megarectum, and other functional anorectal disorders. These studies can assess preoperative and postoperative anorectal function and help in the differential diagnosis of anorectal disorders, and thus they assist the surgeon in carrying out rational therapy.

Anal Canal↗
PubMed1994

[The determination of the ovarian dosage in defecography on a digital C-arm unit].

When using defaecography as a radiological tool for diagnosing the anorectal function in female patients, the ovaries are inevitably directly exposed. With the aim of minimising the ovarian dose applied both the area-dose product and the surface dose above the ovaries were measured during investigations of female patients with a digital C-arm unit. These values were converted into ovarian doses using tissue-air ratios. From the surface dose measured with TLD-100 a mean ovarian dose of 15.6 +/- 8.6 mGy was derived. The contributions of screening and film exposures were similar. A reduction of screening time by 10 seconds or omission of 60 film exposures results in a decrease of ovarian dose by values between 0.7 and 2 mGy. Employing a greater focus-skin distance during defaecography, however, made it possible to reduce the ovarian dose by 26%.

Anal Canal↗
PubMed1988

[Double-exposure defecography following perineal sphincteroplasty].

A new diagnostic method is presented as "Double-Exposure Defaecography". Its advantage is the reliable evaluation of functional parameters of defaecography without the aid of obligatory auxiliary lines in relation to the drawing of the relevant skeletal parts. Less display and effort are needed than in cineradiography. The so called pinching test allows functional, quantitative examination of musculus puborectalis. The evaluation is performed on double-exposed x-ray films. Besides a group of patients suffering from anorectal incontinence and difficulties in defaecation (n = 42), a group of patients (n = 21) with smooth-muscular perineal sphincter replacement was controlled by double-exposure defaecography. This fairly new method of surgery restores continence in 80% of the cases.

Anal Canal↗