Anorectal Angle Research Articles

Simulated Colonic Feces Reveals Novel Contraction Patterns

Simulated Colonic Feces Reveals Novel Contraction Patterns

S0456 Revisiting the Cut-Off for an Abnormal Balloon Expulsion Test: Can We Make Testing More User Friendly?

INTRODUCTION: Chronic constipation (CC) is a common gastrointestinal complaint in clinical practice. Anorectal Manometry (ARM), Balloon Expulsion Testing (BET), and Defecography (DEF) are used to evaluate for dyssynergic defecation (DD) in CC patients. Literature provides poor to moderate agreement between ARM, BET, and DEF. The current threshold for a normal BET is <60 seconds. This threshold, though widely adopted, has not been rigorously validated. Our aim was to determine if a shorter or longer expulsion time offers improved performance characteristics to the current cut off for an abnormal BET of <60-seconds. METHODS: A retrospective cross-sectional study was conducted on 4746 CC patients ≥18 years of age who were referred for AFT at a single tertiary-care center from July 2003 to February 2020. All CC patients underwent an ARM and BET with a sub-set completing an ARM, BET, and DEF (n = 726). Abnormal AFT were defined as the following: ARM = simulated defecation responses with ≤20% anal relaxation; BET = the inability to expel a 50 ml water-filled balloon in ≤60-seconds; DEF = paradoxical contraction, increase anorectal angle, and/or the inability to expel barium contrast. DD was defined as an abnormal ARM and DEF. Linear BET time marks were coded for an abnormal test every 30-seconds: 30–120 seconds. Sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) were calculated for each 30-second BET time point using an abnormal ARM, DEF, and DD as individual state variables. RESULTS: Demographics (N = 4746) were as follows: mean age 48.8 ± 16.4 years (18–93), mean BMI 27.5 ± 7.2, 81.8% female, and 85.3% Caucasian. The BET sensitivity and specificity were similar at 30, 60, 90, and 120 seconds for an abnormal ARM, DEF, and DD (Table 1). The PPV for identifying an abnormal ARM for BET using a threshold of 120 seconds (sec) = 79%, for BET 90 sec = 68.0%, BET 60 sec = 62.1%, and BET 30 sec = 47.7% (Table 1). The NPV for BET 120 sec = 27.9%, BET 90 sec = 44.6%, BET 60 sec = 50.9%, and BET 30 sec = 62.7% (Table 1). Similar profiles for PPV and NPV for abnormal DEF and DD relative to various BET time thresholds (Table 1). CONCLUSION: A BET threshold of <60 seconds offers the best combination of performance characteristics for dyssynergic defecation relative to a few different gold standards and should remain the standard for defining an abnormal BET.Table 1

Pelvic Floor Biometric Changes Assessed by 4D Translabial Ultrassound in Women With Vulvodynia Submitted to Physical Therapy: A Pilot Study of a Randomized Controlled Trial

BackgroundVulvodynia is a disabling condition in which pelvic floor muscles' (PFM) hypertonicity plays an important role. AimTo evaluate biometric changes in PFM in women with vulvodynia undergoing kinesiotherapy treatment protocol (KTP). MethodsA single-blinded randomized controlled trial of 57 women with vulvodynia randomly assigned to either KTP + amitriptyline or amitriptyline alone (controls) for treatment. Four-dimensional translabial ultrasound assessed PFM regarding symphysis-levator distance at rest, anorectal angle at rest, excursion of the levator plate angle, and levator hiatal narrowing. Volunteers underwent a vaginal examination for a cotton swab test (CST), fulfillment of Friedrich criteria score and PFM power of contraction, and completed a diary of sexual pain and frequency of vaginal intercourse. Outcomes were assessed at baseline and after 8 weeks of treatment. OutcomesPrimary outcomes were differences in biometric parameters assessed by four-dimensional translabial ultrasound after treatment, between groups. Secondary outcomes were changes in clinical variables (CST, Friedrich criteria, PFM power of contraction, frequency of intercourse, and intensity of sexual pain) between groups and correlation analysis between biometric parameters and clinical variables. ResultsOnly the KTP group had statistically significant changes in biometric parameters after treatment (symphysis-levator distance: 0.22 ± 0.2, 95% CI = 0.1–0.4, P = .008; levator hiatal narrowing: −0.33 ± 0.2, 95% CI = −1 to −0.2, P = .04). Comparisons between groups showed that symphysis-levator distance (0.3, 95% CI = 0.2–0.6, P = .005) and excursion of levator plate angle (4.9, 95% CI = −0.4 to 10.1, P = .02) improved significantly after KTP treatment. Clinical variables showed greater improvement in the group treated with KTP for CST (difference of −3.7, 95% CI = −7 to −0.4, P = .01), Friedrich criteria (difference of −1.9, 95% CI = −3.2 to −0.6, P = .003), PFM power of contraction (0.3, 95% CI = 0.1–0.6, P = .05) and intensity of sexual pain (reduction of 1.7, 95% CI = −3.1 to −0.2, P = .01). Some clinical and biometric variables correlated positively, for example, frequency of vaginal intercourse and anorectal angle (P = .04; r = 0.25), or inversely, for example, pain intensity at CST and anorectal angle (P = .004, r = −0.31). Clinical ImplicationsThis study provides evidence on efficiency of a physical therapy protocol for improvement of symptoms of vulvodynia and hypertonicity changes. ConclusionThis pilot study suggests that KTP for women with vulvodynia promoted significant changes in PFM biometric measures, consistent with alterations in hypertonicity and clinical improvement.Bardin MG, Giraldo PC, Martinho N. Pelvic Floor Biometric Changes Assessed by 4D Translabial Ultrassound in Women With Vulvodynia Submitted to Physical Therapy: A Pilot Study of a Randomized Controlled Trial. J Sex Med 2020;17:2236–2246.

Anorectal angle at rest predicting successful sacral nerve stimulation in idiopathic fecal incontinence\u2014a cohort analysis

PurposeSacral nerve stimulation is an effective treatment for patients suffering from fecal incontinence. However, less is known about predictors of success before stimulation. The purpose of this study was to identify predictors of successful sacral nerve stimulation in patients with idiopathic fecal incontinence.MethodsConsecutive female patients, receiving peripheral nerve evaluation and sacral nerve stimulation between September 2008 and October 2014, suffering from idiopathic fecal incontinence were included in this study. Preoperative patient’s characteristics, anal manometry, and defecography results were collected prospectively and investigated by retrospective analysis. Main outcome measures were independent predictors of treatment success after sacral nerve stimulation.ResultsFrom, all in all, 54 patients suffering from idiopathic fecal incontinence receiving peripheral nerve evaluation, favorable outcome was achieved in 23 of 30 patients after sacral nerve stimulation (per protocol 76.7%; intention to treat 42.6%). From all analyzed characteristics, wide anorectal angle at rest in preoperative defecography was the only independent predictor of favorable outcome in multivariate analysis (favorable 134.1 ± 13.9° versus unfavorable 118.6 ± 17.1°).ConclusionsAnorectal angle at rest in preoperative defecography might present a predictor of outcome after sacral nerve stimulation in patients with idiopathic fecal incontinence.

Risk factors associated with pain in fusion prostate biopsy.

BackgroundMultiparametric prostate magnetic resonance imaging (mpMRI)–guided fusion prostate biopsy is an emerging technique in the diagnosis of prostate cancer and provides extensive information on the prebiopsy anatomy of the prostate, anus, and rectum. We aimed to investigate the clinical and anatomical risk factors aggravating the pain experienced by patients undergoing mpMRI-guided fusion prostate biopsy.MethodsThe prospective study included 319 patients aged 45–75 years who had a prostate-specific antigen <10 ng/ml and a Prostate Imaging Reporting and Data System ≥3 lesion and underwent combined biopsy (targeted biopsy + 12-core standard prostate biopsy) under local anesthesia (intrarectal lidocaine gel + periprostatic nerve block). Immediately after the biopsy procedure, pain assessment was achieved using Visual Analog Scale (VAS). The relationship between the VAS and 13 clinical parameters was evaluated using ordinal logistic regression analysis.ResultsThe 319 patients had a mean age of 62.39 ± 6.98 years and a median prostate-specific antigen level of 7.20 (range, 5.20–8.50) ng/ml. The VAS was found to be correlated with 4 of 13 parameters, including (i) a shorter prostate–anus surface distance (cutoff value, 55.5 mm), (ii) a narrower anorectal angle (cutoff value, 106.5°), (iii) a larger total prostate volume (cutoff, 61.6 mm3), and (iv) having no history of prior biopsy (biopsy-naive patients).ConclusionAnatomical measurements that can be achieved by using mpMRI images (TPV, PASD and ARA) may be useful in the identification of patients at an increased risk of pain during biopsy and also in taking analgesic precautions in such patients.

Predictive Factors and Effects of Replaced Rectorectal Intussusception on Functional Outcomes in Patients with Rectoanal Intussusception Who Have Undergone Laparoscopic Ventral Rectopexy

Rectoanal intussusception (RAI) treated using laparoscopic ventral rectopexy (LVR) may give rise to rectorectal intussusception (RRI) during defecation postoperatively. However, only a few studies have analyzed the results of LVR using pelvic floor imaging, which is important when interpreting postoperative symptoms in patients with RAI. Thus, this study was designed to find the preoperative variables that may help predict the postoperative occurrence of RRI and to determine whether RRI may have negative effects on bowel symptoms after LVR for RAI. Consecutive patients treated between 2012 and 2017 were included. Defecatory function was evaluated using the Constipation Scoring System (CSS) and the Fecal Incontinence Severity Index (FISI). Defecography was performed before and 6 months after LVR. Of the 66 patients with RAI preoperatively, 34 had mixed obstructed defecation (OD) and fecal incontinence (FI), 18 had OD alone, and 12 had FI alone. Twelve months after surgery, a reduction of at least 50% was observed in the CSS score of 25 patients (52%) with OD and in the FISI of 37 incontinent patients (87%). Postoperatively, RAI was replaced with RRI in 21 and posterior RAI in 2 patients. These anatomical changes were found in patients who had a greater anorectal angle at rest preoperatively. However, the improvement in bowel symptoms was unrelated to the anatomical changes. Improvement in bowel symptoms after LVR for RAI was unrelated to the postoperative occurrence of RRI or posterior RAI, which were found in patients who had a vertical rectum at rest preoperatively.

Prediction of surgical difficulty in minimally invasive surgery for rectal cancer by use of MRI pelvimetry.

BackgroundTechnical difficulties in rectal surgery are often related to dissection in a limited surgical field. This study investigated the clinical value of MRI pelvimetry in the prediction of surgical difficulty associated with minimally invasive rectal surgery.MethodsPatients with rectal cancer who underwent laparoscopic or robotic total mesorectal excision between 2005 and 2017 were reviewed retrospectively and categorized according to surgical difficulty on the basis of duration of surgery, conversion to an open procedure, use of the transanal approach, postoperative hospital stay, blood loss and postoperative complications. Preoperative clinical and MRI‐related parameters were examined to develop a prediction model to estimate the extent of surgical difficulty, and to compare anastomotic leakage rates in the low‐ and high‐grade surgical difficulty groups. Prognosis was investigated by calculating overall and relapse‐free survival, and cumulative local and distant recurrence rates.ResultsOf 121 patients analysed, 104 (86·0 per cent) were categorized into the low‐grade group and 17 (14·0 per cent) into the high‐grade group. Multivariable analysis indicated that high‐grade surgical difficulty was associated with a BMI above 25 kg/m2 (odds ratio (OR) 4·45, P = 0·033), tumour size 45 mm or more (OR 5·42, P = 0·042), anorectal angle 123° or more (OR 5·98, P = 0·028) and pelvic outlet less than 82·7 mm (OR 6·62, P = 0·048). All of these features were used to devise a four‐variable scoring model to predict surgical difficulty. In patients categorized as high grade for surgical difficulty, the anastomotic leakage rate was 53 per cent (9 of 17 patients), compared with 9·6 per cent (10 of 104) in the low‐grade group (P < 0·001). The high‐grade group had a significantly higher local recurrence rate than the low‐grade group (P = 0·002).ConclusionThis study highlights the impact of clinical variables and MRI pelvimetry in the prediction of surgical difficulty in minimally invasive rectal surgery.

SPARC: Wireless Fecobionics Device in dogs

ObjectiveWe developed a novel wireless device (Fecobionics) for mapping colonic and anorectal neuromuscular function. Fecobionics measures pressures, cross‐sectional areas and bending of the device and transmits data wireless to a receiver unit outside the body (figure 1). This study evaluated the safety of the device in dogs relative to the predicate THD SensyProbe device for biofeedback. Furthermore, physiological data were obtained with Fecobionics.MethodsTwelve male Mongrel dogs with 25kg body weight were assigned into two groups: Fecobionics group and predicate control group (N=6 of each). Fecobionics and the predicate device were transanally inserted into rectum. Further, each group was divided into two sub‐groups: The acute group in which the animals were euthanized immediately after the evacuation of the device, and the chronic group in which the animals were terminated after 2 weeks. The animals were monitored daily. Tissue from different colon segments and anorectum were collected after the dogs were euthanized. HE staining and immunofluorescence staining were performed.ResultsAll procedures were performed successfully without complications. All chronic animals showed normal food intake and behavior after the procedure. Wireless transmission of Fecobionics data were without significant data loss or data error. Fecobionics studies demonstrated defecation pressures in the range 60–100cmH2O. The bending of the device, representative of the anorectal angle, was less than 30 degrees. The shape of the bag was obtained from the serial cross‐sectional area measurements. The shape of Fecobionics was cylindrical in rectum and changed to hourglass shape when it passed through the anal canal. No signs of inflammation were identified in the tissue sections examined histologically or immunohistochemically (macrophages and caspase‐3) in both Fecobionics and control groups.ConclusionsWireless Fecobionics is as safe as the predicate device, without inducing macro‐ or microscopic changes or inflammatory status of anorectal muscle. Novel physiological data were obtained. Dogs seems not to have an anorectal angle like humans, which makes defecatory efficacy more dependent on intrarectal pressure and anal sphincter relaxation compared to humans.Support or Funding InformationFundingNIH SPARC OT2OD025308The Fecobionics device (left), the wireless receiver (middle) and the data collection device (right).Figure 1

SPARC: Fecobionics Simulated Defecations in Pigs

Objective. We have developed an integrated Fecobionics device to assess pressures, orientation and bending simultaneously during defecation. This study assessed the feasibility of the Fecobionics device in pigs.Methods. Ten Yorkshire pigs (male, 50–60kg) were divided into groups that was euthanized immediately after the experiment (acute group, n=5) or lived for 2 weeks before the pigs were euthanized (chronic group, n=5). Fecobionics is a bendable probe that contains pressure sensors, motion processing units (MPUs), and electronic circuits. The probe was 13cm long, 13mm OD and contained a bag for distension. The pigs were lightly restrained in a sling. The device was inserted manually through an anoscope into the rectum within half hour after the pig had a normal defecation. The bag was filled with 20–50 ml of saline to provide an urge to defecate. Behavior and signs of discomfort was evaluated during and after the defecation. Pressures, orientation and bending data were collected during defecation. Both the rectum and the anal canal were excised after euthanization for mucosal gross morphological observation and histological examination. Devices were tested after the expulsions for any damage to the electromechanical system, the core and bag.Results. The pigs paid little attention to device insertion if they were distracted by food. Often the pigs became a bit agitated after eating and defecated the device at this point. The device was defecated from few minutes up to 1h after insertion (average 12min). The pressure sensors at the two ends and inside the bag showed simultaneous pressure increase when the pigs contracted the abdominal muscle. The defecation pressure was usually in the range 80–100cmH2O if the pig was not agitated. Device bending was less than 20 degrees during defecations, indicating that the pig does not exhibit an anorectal angle like humans. Fecobionics was slowly pushed out in 10–40 seconds, often with the front hanging from the anus for some time before being dropped. The recovered devices had intact surfaces without exposed electronics. In two cases the bag had a small leak. One device stopped working after being defecated and had a broken wire, likely due to damage when it dropped to the floor. Mucosal damage, bleeding and inflammation were not found in gross morphological observation and histological examination in the acute or chronic groups.Conclusions. Fecobionics is a safe device providing novel defecatory measurements under physiological conditions.Support or Funding InformationNIH SBIR phase 1 grant R43DK112543 and NIH SPARC OT2OD025308

70: Dynamic magnetic resonance imaging of pelvic anatomy following vaginal reconstructive surgery: A prospective study

To describe the impact of native tissue vaginal reconstruction, including vaginal vault suspension, on pelvic anatomy using dynamic magnetic resonance imaging (MRI). This IRB approved prospective cohort study investigated women undergoing intraperitoneal vaginal vault suspension for symptomatic pelvic organ prolapse (POP) with native tissue reconstruction. Enrolled participants underwent dynamic pelvic MRI preoperatively and 3 months postoperatively. Radiographic and anatomic measurements were compared. The H-line (or levator hiatus) was defined as the distance from the pubic symphysis to the posterior anal canal and the M-line (or muscular pelvic floor relaxation) was defined as the decent of the levator plate from the pubococcygeal line (PCL). The PCL represented the level of the pelvic floor and was measured from the inferior border of the pubic symphysis to the last coccygeal joint. Our primary outcome was to compare preoperative MRI measurements to those following surgical treatment. Secondary outcomes were evaluated via validated patient questionnaires pre- and post-operatively. A total of 17 participants were enrolled, 14 completed the study and were included in our analysis. The mean age was 62 years; all participants were white. The majority of participants had Stage III POP, as defined by the Pelvic Organ Prolapse Quantification (POP-Q) scale. Twelve participants (85.7%) underwent a concomitant hysterectomy and 5 participants (35.7%) received a concomitant midurethral sling procedure. There was a significant improvement in several radiographic measurements with straining and/or defecation following vaginal reconstruction, including the H-line, M-line, anorectal angle, and the extent of apical and anterior compartment prolapse. There was no difference regarding pubococcygeal line (PCL), anorectal decent, extent of enterocele, or posterior compartment prolapse. POP-Q measurements improved significantly in all compartments with the exception of perineal body and total vaginal length. Regarding validated questionnaires, PFDI-20 scores improved significantly (102 preop vs. 30 postop, p<0.001) following surgery. While PFIQ-7 scores also improved, this finding did not achieve significance (55 preop vs 24 postop, p=0.164). Native tissue reconstruction with intraperitoneal vaginal vault suspension for symptomatic pelvic organ prolapse not only improves pelvic anatomy and function as defined by POP-Q measurements and PFDI scores, but is also associated with significantly improved measurements on dynamic MRI at 3 months postoperatively.

COMPARATIVE MORPHOLOGY OF THE PIG`S RECTUM AND HUMAN`S RECTUM VIA 3D RECONSTRUCTION

The aim: To define an ability to use pig as biomodel for experimental and clinical studies in order to develop new approaches of treatment of the rectal pathology. Materials and methods: For the research two groups were used. I group includes 50 humans (27 females and 23 males), II group includes 8 vietnamese pot-bellied pigs. After magneresonance Imaging the 3D reconstruction of rectum was made. Results and conclusions: Topography, structure, age and gender peculiarities of pig`s and human`s rectum in comparative aspect are described in this article. With the help of modern methods, namely 3D reconstruction, the structure of the pig`s and human`s rectum was reconstructed. The morphological parameters, such as size of anorectal and rectosigmoid angles, the length of the rectum and its parts, were determinated. The 3D reconstruction demonstrated that size of anorectal and rectosigmoid angles, the length of the pig`s rectum are morphologicaly identical to the same parametres of human`s rectum. Thus, it is proved that pigs can be used as biomodels in experimental and clinical studies for development the new methods of treatment the rectal pathology in humans.

MR defecography detects pelvic floor dysfunction in participants with chronic complete spinal cord injury.

A prospective single arm study. Previously we have demonstrated that magnetic resonance (MR) defecography is feasible in participants with complete spinal cord injury (SCI). The main aim of this study is to evaluate whether MR defecography can provide objective parameters correlating with the clinical manifestations of neurogenic bowel dysfunction (NBD) in participants with SCI. A monocentric study in a comprehensive care university hospital Spinal Cord Injury Center. Previously published MR defecography parameters (anorectal angle (ARA), hiatal descent (M-line) and hiatal width (H-line)) of twenty participants with SCI were now compared to a standardized clinical assessment of NBD. Descriptive statistics, correlations and t-tests for independent samples were calculated. The significantly higher values for the ARA at rest and M-line at rest in participants with SCI correlated with the clinical assessment of bowel incontinence. Furthermore, in nearly half of the investigated SCI cohort the normally positive difference between ARA, M-line and H-line at rest and during defecation became negative suggesting pelvic floor dyssynergia as a potential mechanism underlying constipation in people with complete SCI. In fact, these participants showed a more severe clinical presentation of NBD according to the total NBD score. MR defecography provides objective parameters correlating with clinical signs of NBD, such as constipation and bowel incontinence. Therefore, MR defecography can support pathophysiology-based decision-making with respect to specific therapeutic interventions, which should help to improve the management of NBD.

Intestinal Contents Stayed After Discharge as Low Anterior Resection Syndrome

Background: The lower anastomosis after low anterior resection (LAR) is associated with the development of low anterior resection syndrome (LARS). However, pathophysiology of fragmentation of defecation which is one of LARS remains unknown. Patients and Methods: Between January 2015 and December 2017, eight patients with temporary ileostomy who underwent LAR with double stapling technique (DST) for rectal cancer at our hospital were studied. As the control group, nine patients with temporary ileostomy who underwent proctocolectomy (PC) with DST for ulcerative colitis in the same period were recruited. Defecography was performed two weeks after closure of the ileostomy. The defecation of all patients was evaluated by defecography. Results: In all patients, the descent of the perineum and linearization of the anorectal angle were observed. In patients after PC, all barium could be discharged by some abdominal pressures. On the other hand, in all patients after LAR, barium located anal to the anastomosis could be discharged through the anus, while barium located oral to the anastomosis stayed after discharge, which could not be expelled by maximal abdominal pressures more than 5 minutes after starting evaluation. Conclusion: Remnant intestinal contents after defecation seems to be one of disturbance for defecation after LAR.

Relationship between MRI findings after laparoscopic-assisted anorectal pull-through for anorectal malformations and the functional outcomes

Objective To explore the relationship between MRI findings and defecation function after laparoscopic-assisted anorectal pull-through for anorectal malformations. Methods A retrospective cohort study focused on the findings of MRI performed after laparoscopic-assisted anorectal pull-through for anorectal malformations and no spinal deformity was present in all patients who are currently older than 3 years. Forty-two patients aged from 3 to 16 years (median age was 4 years), whom accepted operation at 3 months to 13 years old(median age was 5 months), and MRI was carried out in 2 to 5 months after operation(median time was 3 months). The MRI manifestations including the relationship between the anorect and the high muscle complex(RAHMC), anorectal angle(AA);the relationship between the anorect and the low muscle complex(RALMC), the rectal maximum diameter(RMD), the fat tissue interposition(FTI) and the development of pelvic floor muscle(PFM) were reviewed and summarized. Statistically, the differences of MRI manifestations in different defecation function index, including the degree of voluntary bowel movements, soiling, constipation and Krickenbeck score were evaluated respectively with Chi-square test or rank sum test. Results statistically, There was significant differences among the groups with different degree of voluntary bowel movements, soiling and Krickenbeck score in the RAHMC (P 0.05) . Conclusions The deviation of the anorect from the high muscle complex which showed in the postoperative MRI pictures suggested the poor prognosis, and well-developed pelvic floor muscles which indicated in the MRI was not the sufficient predictor for good outcome. Postoperative anorectal angle obtained in the MRI can be used as an objective indicator of prognosis. Key words: Rectum; Anus diseases; Laparoscopes; Magnetic resonance imaging

Necessity of early correction of anal-coccygeal ligaments in traumatic damage to a coccyx

In order to prevent and correct the defecation disorders after destruction of the anococcygeal ligament, the meth-od of restoring its functional capacity was proposed (Patent of Ukraine for Invention No. 115280 “Method for Coccyx Re-moving”).&#x0D; It is proved that the damaging effect in the area of the traction and contraction mechanism of action on the rectum in 90.0% leads to continence disorders due to changes in the size of the anorectal angle due to the persistent disorders of the anococcygeal ligament function. The developed special mathematical model of the anococcygeal ligament function testifies that, when it is destroyed, the change in the anorectal angle value may reach changes in its value up to ≈63°, which distorts the direction of the anal canal and the distal rectum. Restoration by simulating of the anatomical fixation of anococcygeal ligament connection after its damage creates conditions for resto-ration of its physiological functioning.

MR Defecography in Assessing Functional Defecation Disorder: Diagnostic Value of the Defecation Phase in Detection of Dyssynergic Defecation and Pelvic Floor Prolapse in Females

Objective: Dyssynergic defecation (DD) and pelvic floor prolapse often coexist in female functional defecation disorder. A retrospective study was performed to evaluate the ability of dynamic MR sequences with the straining and defecation phase to detect paradoxical puborectalis contraction and occult multiple-compartments disorders. Methods: Fifty-three females clinically diagnosed with DD underwent magnetic resonance defecography. The dynamic sequences consist of rest, squeeze, straining, and defecation. The straining phase (pre rectal filling) and defecation phase (post rectal filling) were acquired to assess for pelvic floor relaxation and pelvic organ descent. MR images were analyzed by 2 radiologists with regard to paradoxical puborectalis contraction (changes in the anorectal angle [ARA]) and the presence of pelvic organ prolapse in straining phase and defecation phase independently. Statistical analysis was performed using Wilcoxon’s matched-pairs signed-ranks test and Crosstabs test for matched pairs. Results: Among the 53 patients with DD, 24 individuals (45.3%) were diagnosed DD with multifocal disorders. Comparison between the straining and the defecation phase revealed that there was no significant difference in the change of the ARA (p > 0.05), while significant differences were found in cystocele, vaginal or cervical prolapse, rectocele and descending perineum syndrome between the straining and the defecation phase (p < 0.05). The defecation phase with impaired evacuation distinguished additional anterior/middle compartments findings in female DD patients. Conclusion: The straining phase and the defecation phase have the same ability in assessing paradoxical puborectalis contraction of the DD. Compared with the straining phase, the defecation phase provides the maximum stress to the pelvic floor resulting in complete levator ani relaxation. In addition to diagnosing the abnormal anorectal function, the defecation phase with the discharge of the rectal filling demonstrates maximum anterior/middle pelvic organ descent in DD patients.

The anatomy of transanal minimally invasive surgery: Perineal distances and transanal angles.

The recent interest in transanal, minimally invasive surgery has highlighted the importance of an in depth understanding of this complex region. We applied data from an anatomical study of the perineum to the concept of transanal minimally invasive surgery with the aim to describe more accurately anatomy relevant to this surgical technique. A consecutive series of adult patients undergoing colonoscopy were approached for consent to measure dimensions and angles of the perineum before the examination. Distances from the posterior margin of the anus to the coccyx, and the anterior margin of the anus to the posterior edge of the scrotum or introitus were measured. Then, using a pediatric proctoscope and a protractor, the anoperineal angle and the recto perineal angles were measured. The anorectal angle was derived from these measurements. Data is described using means and standard deviations. Measurements were obtained from 106 patients undergoing elective colonoscopy for average risk screening with no history of defecatory disorder. Posterior perineal length was similar in both sexes (4.5 cm ± 0.9 in women and 4.6 cm ±0.7 in men) but the anterior perineum was significantly shorter in women (2.5 ± 0.8). The mean anoperineal angle was 93° (±9), and mean rectoperineal angle was 73° (±9). These angles varied significantly between the sexes. The mean anorectal angle (derived) was 160° (±9), and did not differ significantly between the sexes. There was no correlation between the posterior perineal length and ano perineal, recto perineal, or anorectal angles. Limitations: small sample size. Anoperineal and recto perineal differ significantly between the sexes. Surgeons using transanal minimally invasive surgical techniques should expect to alter the alignment of their dissection accordingly. This study shows the magnitude of the differences that can exist. Clin. Anat. 32:68-72, 2019. © 2018 Wiley Periodicals, Inc.

Defecography in contemporary coloproctological diagnostics

Evacuatory difficulty is a common problem covering a large spectrum of disorders, from constipation to faecal incontinence. In addition to a visit to a surgeon-proctologist, the diagnosis of impaired defecation often requires urological and gynaecological evaluation. Many pathologies causing evacuatory difficulty, such as full thickness rectal prolapse, reduced sphincter tone and haemorrhoidal disease, can be detected by clinicians already at the stage of physical examination. A large group of pathologies may be detected using standard diagnostic techniques such as colonoscopy and pelvic imaging, e.g. computed tomography, magnetic resonance, and transabdominal/transrectal/transvaginal ultrasonography. However, certain abnormalities are only visible during functional pelvic examination. These include rectocele, sigmoidocele, enterocele, internal intussusception, cystocele, and spastic pelvic floor syndrome. Defecography is guided by either X-ray or MRI. Pelvic function may be also assessed using transperineal ultrasonography. Defecography involves 4 phases: rest, forced contraction, strain, and defecation. The anorectal angle and, in the case of MRI, the PCL line (which is a reference point for most measurements), are determined in order to evaluate the position and mobility of pelvic organs. Pelvic function evaluation helps differentiate patients with evacuatory difficulties requiring surgical intervention from those who need conservative treatment (exercises, electrostimulation). Furthermore, it helps choose an appropriate technique and surgical access, as well as select patients requiring a more interdisciplinary approach.

Application of Rectal Prolapse Constipation Balloon in Single Auxiliary Defecation

To explore the application value of rectal prolapse constipation balloon in single auxiliary defecation. Forty-one patients with moderate or severe rectocele were treated with a rectocele constipation balloon through the vagina. The defecography and VAS scores were compared before and after implantation. There was a significant difference between the anorectal angle, rectocele, and VAS scores before and after intervention in defecography (P<0.01). A single assisted defecation of the rectocelicular constipation balloon is feasible.

Fecobionics: A Novel Bionics Device for Studying Defecation.

During defecation, solid, semisolid or liquid stools are eliminated via the anus in a complex physiological process. Up to 25% of the population are affected by anorectal disorders that are poorly recognized and treated. We developed a new bionics device, a simulated stool named Fecobionics, to replace several current tests of anorectal function. Fecobionics was developed to simulate the defecation process that depends on rectal forces, the anorectal size angle, and anorectal size and sensitivity. Fecobionics provided axial pressure signatures, measurement of bending (anorectal angle) and geometric mapping in a single examination. It had the consistency and shape of normal stool. The device had a soft core with embedded electronics and a bag for distension. The paper describes the device development and validation. Furthermore, data were obtained in preliminary experiments in pigs, healthy human subjects and patients with focus on four important features of the system, i.e. measurements of pressure signatures, bending characteristics, impedance measurements and data transmission. Accurate pressure and orientation data as well as geometric profiles were successfully obtained on the bench as well as in vivo in pigs and human subjects during defecation. Fecobionics is a novel technology imitating defecation. The clinical future ultimately depends on its ability to impact on daily treatment of anorectal disorders. A potential long-term clinical application is use of the device for biofeedback training for dyssynergic defecation.