Anorectal Angle Research Articles

Frequency, spectrum, and factors associated with fecal evacuation disorders among patients with chronic constipation referred to a tertiary care center in northern India.

Data on fecal evacuation disorder (FED) causing chronic constipation (CC) is scanty in India. Prospectively maintained data of 249 consecutive patients with CC (Rome III) referred for investigations were retrospectively analyzed. Of 249 patients (43.7 ± 16.2years, 174 males), 135/242 (55.8%), 57/249 (22.9%), and 83/136 (61.0%) had abnormal balloon expulsion test (>200g), anorectal manometry [>100mmHg resting pressure (n = 4), >167mmHg squeeze pressure (n = 46), and both (n = 7)], and defecography (anorectal angle not opening by >15° during defecation, perineal descent ≥4cm, and/or rectocele), respectively. Though 181/249 (72.6%) had one test abnormality, 86/249 (34%) had FED (greater than or equal to two abnormalities), 44/65 (67.6%) of whom had a defecation index ≤1.4. Rome III criteria for irritable bowel syndrome were equally fulfilled by patients with and without FED [74/83 (89%) vs. 117/144 (81.2%); p = ns]. On univariate analysis, straining duration, prolonged straining [≥30min; 21/39 (53.8%) vs. 15/65 (23.1%); p = 0.002], incomplete evacuation [75/77 (97.4%) vs. 95/114 (83.3%); p = 0.004], and >3 stools/week [60/75 (80%) vs. 76/128 (60%); p = 0.004] were commoner among the FED patients though age, gender, symptom duration, mucus, manual evacuation, and stool forms were comparable. Resting and squeeze pressures and balloon volume at maximum tolerable limit were higher, and the sphincter tended to be shorter in FED. Prolonged straining, incomplete evacuation, and squeeze pressure were significant on multivariate analysis. Manometry and defecography abnormalities were commoner among the female FED patients. FED is not uncommon, which fulfills the Rome III criteria for IBS, and prolonged straining may be suggestive; abnormal defecography and manometry are commoner in female.

Interobserver agreement of multicompartment ultrasound in the assessment of pelvic floor anatomy.

To assess the interobserver agreement of pelvic floor anatomical measurements using multicompartment pelvic floor ultrasound. Females were recruited from the urogynaecology/gynaecology clinics between July and October 2009 and underwent multicompartment pelvic floor ultrasonography (PFUS) using two-dimensional (2D) transperineal ultrasound (TPUS), high-frequency 2D/three-dimensional (3D) endovaginal ultrasound (EVUS) using a biplane probe with linear and transverse arrays and a 360° rotational 3D-EVUS. PFUS measurements were independently analysed by two clinicians. 158 females had PFUS assessment. Good-to-excellent interobserver agreement was observed for bladder-symphysis distance at rest and valsalva, urethral thickness, urethral length, urethral volume, levator hiatus area and width, anteroposterior diameter and anorectal angle. Lins Correlation was used to calculate the interobserver agreement and Bland-Altman plots were created to demonstrate the agreement between the researchers. There was also a good-to-excellent agreement between the two clinicians for the assessment of pelvic organ prolapse (POP) in the anterior, middle and posterior compartment. Multicompartment PFUS is a reliable tool in the anatomical assessment of pelvic floor measurements and POP. We found a good-to-excellent agreement between the two assessors in the assessment of pelvic floor measurements for all three pelvic floor compartments and suggest that multicompartment PFUS could be considered as a systematic integrated approach to assess the pelvic floor.

Accurate Differentiation of Dyssynergic Defecation Patients from Normal Subjects Based on Abnormal Anorectal Angle in MR Defecography

Abstract Objective: We aimed to study the kinematic indices of the pelvic floor, anorectal angle and the descent of perinea, and the differing movement, in dyssynergic defecation patients in comparison with healthy controls, based on MR defecography. Methods: Twenty-two individuals involved with dyssynergic defecation constipation and fourteen healthy asymptomatic subjects fell into this study. In four dynamic pelvic floor MRI indices, namely paradox (unusual change of anorectal angle), perineal descent during straining, perineal ascent, and narrowing of anorectal angle at squeeze, were measured in patients and healthy subjects. Results: Paradox Index had the highest sensitivity (95.45%) and specificity (92.86%) for detection of dyssynergic defecation, with an R2 value of near 1 (0.902). The sensitivity and specificity of other indices were not high; therefore, no significant improvement could be achieved using other indices along with Paradox Index. Negative Predictive Value (92.85%) and Positive Predictive Value (95.45%) were only high in Paradox Index. Conclusion: Paradox Index was indicated to be the best finding of MR defecography for identifying dyssynergic defecation patients from healthy controls. Hence, MR defecography could be exploited as an authentic tool to manifest the patients the paradoxical function and the relevant muscles of pelvic floor, which could enhance their imagination of the correct defecation pattern during their treatment.

Effects of posture on anorectal angle and defecated volume:stool simulation using defecography

Effects of posture on anorectal angle and defecated volume:stool simulation using defecography

MR Defecography, a Diagnostic Test to Evaluate the Pelvic Floor Motion in Patients with Dyssynergic Defecation after Biofeedback Therapy

Background: Dyssynergicdefecation is a major cause of chronic functional constipation as a common digestive complaint. We clinically evaluated the effects of biofeedback therapy on the pe lvic floor motion indices through magnetic resonance (MR) defecography, quality of life and depression in patients with dyssynergic defecation. Methods: In this clinical trial study, among patients referring to the Colorectal Clinic of Hazrat Rasoul Hospital, 22 subjects were randomly assigned into two equal groups (n= 11) to receive either standard only or biofeedback and standard therapy. Dynamic changes of the pelvic floor were mea sured by MR defecography. During the simulated defecation, two MR defecography dynamic indices including abnormal anorectal angle change an d perineal descent were measured before and after

Influence of body posture on defecation: a prospective study of "The Thinker" position.

We hypothesized that bending the upper body into what we have termed "The Thinker" position facilitates defecation.This study aimed to assess the influence of "The Thinker" position on defecation. This is the prospective single-group study. Patients who could not evacuate the paste in normal sitting position on cinedefecography between January and June 2013 were enrolled in this study. Cinedefecography was first performed in the sitting position; if the patient was unable to evacuate the paste, images were obtained in "The Thinker" position. Patients who were able to evacuate the paste were excluded from the study. Anorectal angle (ARA), perineal plane distance (PPD), and puborectalis length (PRL) during straining in both positions were measured from the radiographs. Twenty-two patients unable to evacuate the barium paste underwent cinedefecography in "The Thinker" position. Seventeen patients were female, average age of 56 (range 22-76) years. "The Thinker" position had significantly wider ARA than the sitting position (113° vs. 134°, respectively; p=0.03), larger PPD (7.1 vs. 9.3cm, respectively; p=0.02), and longer PRL (12.9 vs. 15.2cm, respectively; p=0.005) during straining. Eleven patients could evacuate completely in "The Thinker" position. "The Thinker" position seems to be a more efficient method for defecation than the sitting position. This technique may be helpful when retraining patients with constipation.

Other options in the treatment of fecal incontinence

Fecal incontinence (FI) is a debilitating condition. Luckily, there are several new treatment options recently introduced or being introduced in the near future. Conservative or “non-operative” management of FI is the first step in management of a patient suffering from FI. Retrograde colonic irrigation is one alternative and is especially valuable in patients suffering from concomitant constipation. Anal plugs are disposable devices that control continence by blocking the passage of stool and may be helpful in selected groups of patients. Sacral nerve stimulation is widely used in the treatment of patients with FI and surgical repair of internal and external procidentia in patients with fecal incontinence has recently gained more interest. At the same time, dynamic graciloplasty and artificial bowel sphincter are rarely used any longer in the management of these patients. There are several treatments that are yet not FDA approved for treatment of patients with FI. The Magnetic anal reinforcement system is a novel device designed to augment the native anal sphincter. This treatment option has demonstrated good results in limited sized series of patients. The post-anal sling procedure, Topas™, has a concept similar to the TVT procedure for urinary stress incontinence. The sling is implanted dorsal to the anal canal with the aim to augment the puborectalis muscle and to restore a normal anorectal angle and a better anal sphincter function. An FDA regulated trial is presently conducted in the US. Regenerative medicine, stem cell therapy, may be the ultimate option to treat FI by regenerating impaired anal muscle. There are currently no validated techniques using this approach but there is an active research ongoing.

Ultrasound Imaging of the Anal Sphincter Muscles: Comparison Between Endoanal and Transcutaneous Approaches

Introduction: Damage to the anal sphincter muscles is extremely common after vaginal birth and is a major cause of anal incontinence in women. Endoanal US imaging is currently the gold standard to diagnose occult injuries to the anal sphincter muscles. 3D-US imaging of the anal sphincters can also be performed using a transcutaneous (transperineal) approach. Our goal was to compare these two US techniques in assessing the internal anal sphincter (IAS), external anal sphincter (EAS) and puborectalis muscle (PRM). Methods: Studies were performed in 5 nulliparous women using the endoanal BK probe and Philips endo-vaginal probe. For the endoanal approach: the imaging was done using the standard 16 mm diameter anal US probe placed endo-luminally. Endo-vaginal images that provide views of the puborectalis muscle (PRM) were also obtained in each subject using the BK probe. For transcutaneous US imaging, the transducer was placed on the perineum; it was directed in the posterior direction to image the anal sphincters and in the cranial direction to image the PRM. Endoanal and transcutaneous US volumes were analyzed along the cranio-caudal length of the anal canal (every 2.5 mm) to visualize details of the IAS, EAS and PRM. Images were reviewed by DCK, RKM and an experienced US radiologist (DHP). Results:Figure 1 shows views of the IAS and EAS from the endoanal and transcutaneous approaches. Figure 2 shows the PRM and the pelvic floor hiatus from two approaches. Image analysis suggests the following pros and cons between the two US imaging methods. The pros of the transcutaneous approach are: 1) better global view of the IAS and EAS muscles. In addition to circular portions of the EAS, transverse perinea and perineal body, two important components of the EAS muscle complex are also visualized; 2) no deformation related to the US transducer probe in the anal/vaginal canal; 3) ability to record dynamic changes in the anorectal angle and pelvic floor hiatus with voluntary contraction. The limitation of the transcutaneous approach is that the images are not clear with regards to the outer margins of the EAS.Figure 1Figure 2Conclusion: Transcutaneous 3D-US imaging is a patient friendly (no probe insertion into the anus or vagina) technique to image the anal sphincters, puborectalis muscle and pelvic floor hiatus. The transcutaneous approach may provide better information on structures such as the perineal body and transverse perinea, which are commonly implicated in obstetrical injury and are the key components of the EAS.

Three-dimensional ultrasound of the female pelvic floor and 3D-power doppler angiography to assess endopelvic vascularization in pregnancy and puerperium

Introduction and hypothesis: We studied ten different three-dimensional ultrasound (3D-US) and three-dimensional Power-Doppler angiography (3D-PDA) variables to assess female pelvic floor status and endopelvic vascularization. We hypothesize that 3D-US is a reliable method to determine and evaluate changes occurring in the pelvic floor during normal pregnancy and puerperium, and can be used by any urogynecology specialist with US-imaging experience. We aimed to validate this method for clinical application. Materials and methods: We performed a prospective study of 162 nulliparous pregnant women evaluated at weeks 12, 28 and 36, and at 48 hours postpartum and three months post-delivery. At each of the five visits, we performed transperineal 3D-US of the pelvic floor and 3D-PDA to assess periurethral vascularization. Results: Quantification of the vaginal anterior vaginal wall anchors (AWA) is an anthropometric parameter sensitive to changes in pregnancy and puerperium. Significant differences in AWA were observed according to delivery mode, being lower in vaginal deliveries than cesarean sections and even lower in prolonged labor deliveries and those in which episiotomy was performed. Posterior uretrovesical angle (UVA) increased during pregnancy, partially recovering after delivery although less so in those with epidural analgesia. Urethral sphincter volume (USV) decreased significantly during labor and postpartum. Periurethral vascularization increased during pregnancy and decreased significantly after delivery. Levator hiatus area (LHA) increased during pregnancy and decreased after delivery. Patients who received epidural analgesia and oxytocin showed better LHA recovery. Prolonged labor and greater fetal head circumference increased LHA. The anorectal angle (ARA) increased during pregnancy and decreased postpartum. Conclusion: All 3D-US variables and their changes during pregnancy, childbirth and the postpartum period are measurable using the Virtual Computer-Aided Analysis (VOCAL method) with automatic threshold, which is more reliable and faster for measuring USV. AWA as an important new biometric parameter should be included in the study of the pelvic floor.

Effects of posture on anorectal angle and defecated volume:stool simulation using defecography

Effects of posture on anorectal angle and defecated volume:stool simulation using defecography

Correlation between functional outcomes and postoperative pelvic magnetic resonance imaging in children with anorectal malformation.

Background:Though the outcomes in operated children with anorectal malformation (ARM) have greatly improved, postoperative soiling and constipation remain major issues. Among the various factors described for poor outcomes; misplaced bowel, hypoplastic sphincters and obtuse anorectal angle bear special mention. The aim of this study was to compare the stooling outcomes, type of anomalies and surgical procedure with postoperative pelvic magnetic resonance imaging (MRI).Materials and Methods:This was a cross-sectional study involving operated children of ARM who had at least 2 years of follow-up, and who were at least 3 years of age. The subtypes of ARM, surgical procedures, and functional outcomes were documented using the Krickenbeck classification. All children were subjected to a pelvic MRI.Results:Thirty-three eligible children were part of this study. Twenty-two patients underwent posterior sagittal anorectoplasty, seven patients underwent abdominoperineal pull-through (APPT) and four patients underwent perineal operations. Local abnormalities were present in 66% patients, and 34% had abnormalities of the spine detected on MRI. Poorer stooling outcomes were twice as common in children with local pelvic MRI abnormalities as compared to asymptomatic children. The highest incidence of local abnormalities were seen in patients treated with APPT (P = 0.0001). No significant difference in the pelvic MRI was seen among children who were constipated and those who had soiling.Conclusion:MRI is a useful imaging modality in operated children of ARM with poor stooling outcomes. Local abnormalities were the most common in children undergoing abdominoperineal pull-through procedure.

High-resolution anorectal manometry and dynamic pelvic magnetic resonance imaging are complementary technologies

Dynamic pelvic magnetic resonance imaging (DP-MRI) offers a comprehensive evaluation of pelvic organ structure in addition to functional information regarding evacuation. Opportunity to apply this technology can be limited due to regional lack of availability. Ideally, clues from standard anorectal testing could predict abnormalities on DP-MRI, leading to its efficient use. The aim of this study is to determine whether high-resolution anorectal manometry (HR-ARM) correlates with findings on DP-MRI. This is a retrospective study of HR-ARM performed on patients with constipation who also underwent DP-MRI. Studies were reviewed for significant findings including posterior pelvic organ prolapse, rectocele > 3 cm, rectal intussusception, and anorectal angle. Statistical analysis was performed using Pearson's correlation coefficient, Student's t-test, and Fisher's exact test. Twenty-three patients undergoing HR-ARM (age range 25-78) also underwent DP-MRI. All were female; 76% were Caucasian. Twenty had significant structural findings: small pelvic prolapse (n = 2), moderate pelvic prolapse (n = 10), large pelvic prolapse (n = 9), rectocele (n = 8), or rectal intussusception (n = 3). Only intrarectal pressure on HR-ARM weakly correlated with size of rectocele (r = 0.46; P = 0.03) and degree of pelvic organ prolapse (r = 0.48; P = 0.02). The remainder of the HR-ARM parameters did not significantly correlate with DP-MRI findings. Patients with dyssynergy were not more likely to have rectoceles > 3 cm (44.4% versus 35.7%; P = 0.5) or large prolapses (44.4% versus 50%, P = 1.0), compared with those without dyssynergy, on HR-ARM. We were unable to find a correlation between HR-ARM findings and structural pelvic defects on DP-MRI. Therefore, these two technologies provide complementary information in the evaluation of defecatory dysfunction.

Sonographic predictors of obstructive defecatory dysfunction.

We aimed to evaluate the association between obstructive defecatory symptoms in women with levator ani deficiency (LAD), worsened minimum levator hiatus measurements, widened anorectal angle (ARA), and increased levator-plate descent angle (LPDA). Using a cross-sectional study design, patients who had undergone 3D endovaginal ultrasound (3D EVUS) imaging of the pelvic floor were sampled and categorized into two groups: those with and those without obstructive defecatory symptoms (ODS) based on their Colorectal and Anal Distress Index (CRADI-8) questionnaire. The levator ani (LA) muscle was scored based on severity of defect. ARA and LPDA were measured and dichotomized (ARA ± 170°; LPDA ± 9°. One hundred patients were analyzed: 52 asymptomatic and 48 with ODS. The mean (standard deviation ) age was 59 years (SD ±14.97). There was no difference in the distribution of LAD severity between groups (p = 0.1438) or mean minimal levator hiatus (MLH) (p = 0.3326). ARA and LPDA were significantly different in those with ODS compared with their asymptomatic counterparts (p < 0.0001 and 0.0004, respectively) (Table 1). On multivariable logistic regression, ARA and LPDA were included in the final model. Patients with an ARA >170° had seven times the odds of ODS than those with ARA ≤170° [odds ratio (OR) = 7.01, 95 % confidence interval (CI) 2.30-21.35; p = 0.0006). Patients with an LPDA <9° had 3 times the odds of ODS than those with an LPDA ≥9° (OR = 3.30, 95 % CI 1.22, 8.96, p = 0.0190). This study demonstrates that increased levator plate descent and widened ARA as measured on 3D endovaginal ultrasound imaging are associated with ODS.

The value of fluoroscopic defecography in the diagnostic and therapeutic management of defecation disorders in children.

Defecography is a study to assess anorectal function during evacuation. To investigate the value of fluoroscopic defecography in directing diagnostic and therapeutic management in children with defecation disorders. 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. 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. 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.

Evacuation proctography: a reappraisal of normal variability

Interpretation of evacuation proctography (EP) images is reliant on robust normative data. Previous studies of EP in asymptomatic subjects have been methodologically limited. The aim of this study was to provide parameters of normality for both genders using EP. Evacuation proctography was prospectively performed on 46 healthy volunteers (28 women). Proctograms were independently analysed by two reviewers. All established and some new variables of defaecatory structure and function were assessed objectively: anorectal dimensions; anorectal angle changes; evacuation time; percentage contrast evacuated; and incidence of rectal wall morphological 'abnormalities'. Normal ranges were calculated for all main variables. Mean end-evacuation time was 88 s (95% CI: 63-113) in male subjects and 128 s (95% CI: 98-158) in female subjects; percentage contrast evacuated was 71% (95% CI: 63-80) in male subjects and 65% (95% CI: 58-72) in female subjects. Twenty-six (93%) of 28 female subjects had a rectocoele with a mean depth of 2.5 cm (upper limit = 3.9 cm). Recto-rectal intussusception was found in nine subjects (approximately 20% of both genders); however, recto-anal intussusception was not observed. Only rectal diameter differed significantly between genders. Qualitatively, three patterns of evacuation were present. This study defines normal ranges for anorectal dimensions and parameters of emptying, as well as the incidence and characteristics of rectal-wall 'abnormalities' observed or derived from EP. These ranges can be applied clinically for subsequent disease comparison.

Elimination communication as colic therapy

Colic is generally defined as excessive crying in early infancy and can have negative consequences on the infant as well as on the infant’s family life. Excessive crying can result in escalating parental stress levels, abusive caregiver response, increased risk of shaken baby syndrome and parental postpartum depression. In addition to excessive crying, symptoms and descriptors of infant colic include inconsolable crying, screaming, legs drawn up against the abdomen, furrowing of eyebrows, distended abdomen, arched back, passing gas, post-feeding crying and difficulty defecating. There are few well-designed, reproducible, randomized, large-scale studies which demonstrate efficacy of any therapeutic method for colic. An unexplored etiology is that colic is functionally related to a decrease in stooling frequency. Gut distention may periodically result in intensifying discomfort for the infant and in concomitant inconsolable crying. Elimination communication (EC; also known as Natural Infant Hygiene and sometimes referred to as infant potty training, baby-led potty training or assisted infant toilet training) involves the use of cues by which the infant signals to the caregiver that the infant needs to micturate or defecate. Such cues can include types of crying, squirming, straining, wriggling, grimacing, fussing, vocalizing, intent look at caregiver, red face, passing gas and grunting, many of which are the same initial symptoms related to the onset of colicky infant states. A caregiver’s attentive and nurturant response to an infant’s cues involve uncovering the infant’s intergluteal cleft and cradling the infant gently and non-coercively in a supported, secure squatting position. This position will increase the infant’s anorectal angle thus facilitating complete defecation. It is hypothesized that effective and timely elimination will cause increased physical comfort for the infant; colic symptoms will concomitantly decrease.

MRI anatomy of anteriorly displaced anus: what obstructs defecation?

Anteriorly displaced anus is an anomaly that is debated with regard to its nomenclature, diagnosis and management. To describe MRI anatomy of the anal canal in children with anteriorly displaced anus and its impact on the process of defecation. We prospectively examined ten children (7 girls, 3 boys; age range 7months to 8years, mean 3years) with anteriorly displaced anus between August 2009 and April 2012. Noncontrast MRI examinations were performed on a 1.5-T magnet. T1- and T2-weighted turbo spin-echo images were acquired in axial, sagittal and coronal planes of the pelvis. The anorectal angle and the relative hiatal distance were measured in mid-sagittal images, and compared with those of a control group using the Mann-Whitney test. In children with anteriorly displaced anus, no anatomical abnormality was depicted at the level of the proximal anal canal. However, the distal anal canal was displaced anteriorly, running out its external muscle cuff, which remained un-displaced at the usual site of the anus. This changes the orientation of the central axis of the anal canal by passing across instead of along the fibers of the longitudinal muscle coat. Children with anteriorly displaced anus had a more obtuse anorectal angle (mean 112.1°), which was significantly greater than that of the control group (mean 86.2°). MRI is a valuable tool in studying the anatomy of the anal canal in children with anteriorly displaced anus. The abnormal orientation of the longitudinal muscle across the anal canal can explain the obstructed defecation in these children. Based on this study, it might be of interest to use MRI in studying equivocal cases and children with unexplained constipation.

Morphometry of the Pelvic Floor Muscles in Women With and Without Provoked Vestibulodynia Using 4D Ultrasound

It has been suggested that pelvic floor muscles (PFMs) play an important role in provoked vestibulodynia (PVD) pathophysiology. Controversy in determining their exact contribution may be explained by methodological limitations related to the PFM assessment tools, specifically the pain elicited by the measurement itself, which may trigger a PFM reaction and introduce a strong bias. The aim of this study was to compare PFM morphometry in women suffering from PVD to asymptomatic healthy control women using a pain-free methodology, transperineal four-dimensional (4D) ultrasound. Fifty-one asymptomatic women and 49 women suffering from PVD were recruited. Diagnosis of PVD was confirmed by a gynecologist following a standardized examination. All the participants were nulliparous and had no other urogynecological conditions. The women were evaluated in a supine position at rest and during PFM maximal contraction. Transperineal 4D ultrasound, which consists of a probe applied on the surface of the perineum without any vaginal insertion, was used to assess PFM morphometry. Different parameters were assessed in sagittal and axial planes: anorectal angle, levator plate angle, displacement of the bladder neck, and levator hiatus area. The investigator analyzing the data was blinded to the clinical data. Women with PVD showed a significantly smaller levator hiatus area, a smaller anorectal angle, and a larger levator plate angle at rest compared with asymptomatic women, suggesting an increase in PFM tone. During PFM maximal contraction, smaller changes in levator hiatus area narrowing, displacement of the bladder neck, and changes of the anorectal and of the levator plate angles were found in women with PVD compared with controls, which may indicate poorer PFM strength and control. Using a reliable and pain-free methodology, this research provides sound evidence that women with PVD display differences in PFM morphometry suggesting increased tone and reduced strength.

Assessment of pelvic floor dysfunctions using dynamic magnetic resonance imaging

PurposeThe purpose of this study was to assess pelvic floor dysfunction using dynamic MRI. Material and methodsA prospective study was carried out on 21 consecutive patients presented during February 2013 to June 2013 with pelvic pain, difficulty in defecation, constipation or organ prolapse. Pelvic floor was imaged using T2-weighted and fast imaging employing steady-state acquisition sequences. Pubococcygeal line was used as the line of reference which further allowed measurement of width and vertical descent of levator hiatus. Anorectal angle was measured to assess relaxation and contraction of puborectalis muscle. Grading of prolapse was classified as mild, moderate and severe. All data were recorded both in resting and during straining phase. ResultsA total of 21 patients were studied, with a mean age of 37.3 (9.4) years with 15 (71.4%) females and 6 (21%) males. Dynamic MR revealed cystocele and rectocele in 7 (33.3%) patients, each. Three (14.28%) patients had enteroceles and spastic pelvic syndrome, each. Only one patient (4.76%) had descending perineal syndrome. Intussusception was observed in 10 (47.6%) patients with commonest type being intra rectal seen in 7 (33.3%) patients. ConclusionDynamic MRI is an ideal, non invasive technique which does not require patient preparation for evaluation of pelvic floor. It acts as one stop shop for diagnosing single or multiple pelvic compartment involvement in patients with pelvic floor dysfunction.

Conventional videodefecography: Pathologic findings according to gender and age

ObjectivesTo review the most common disorders depicted with conventional videodefecography, and to compare the defecographic abnormalities between symptomatic patients according to their gender and age. MethodsConventional videodefecography studies of 300 patients (24 men, 266 women; mean age – 57.7) performed in a 32-month period were reviewed for the following parameters: anorectal angle, movement of the pelvic floor, intussusceptions, incontinence and rectocele. The results were analyzed using the chi-square test. ResultsNormal findings were observed in 16.7% men and 7.5% women. In women, the most frequent pathological findings were rectocele (62%), descending perineum syndrome (42.8%), intussusceptions (33.8%), incontinence (10.5%), dyskinetic puborectalis syndrome (9.4%) and rectal prolapse (4.5%); in men the most frequent pathology was the dyskinetic puborectalis syndrome (37.5%). This syndrome is more likely in men than in women (p=0.01; OR 5.78); descending perineum syndrome (p=0.027; OR 2.8) is more likely to occur in women.Women with perineal descent younger than 50 years frequently present an increased descent during evacuation (81.8%), while those older than 50 years already have a low pelvic floor during rest (60.3%) (p<0.001; OR 6.8), with little change in evacuation. ConclusionVideodefecographic findings vary with age and gender.