Puborectalis Research Articles

Levator ani muscle volume and architecture in normal vs. muscle damage patients using 3D endovaginal ultrasound: a pilot study.

This study aimed to compare the difference in levator ani muscle (LAM) volumes between 'normal' and those with sonographically visualized LAM defects. We hypothesized that the 'muscle damage' group would have a significantly lower muscle volume. The study included patients who had undergone a 3D endovaginal ultrasound. The normal (NM) and damage (DM) muscle groups' architectural changes were evaluated based on anterior-posterior (AP), left-right (LR) diameter, and minimal levator hiatus (MLH) area. The puboanalis-puboperinealis (PA), puborectalis (PR), and pubococcygeus-iliococcygeus (PC) were manually segmented using 2.5 vs. 1.0 mm to find the optimal sequence and to compare the volumes between NM and DM groups. POPQs were compared between the NM and DM groups. The 1.0-mm segmentation volumes created superior volume analysis. Comparing NM to the DM group showed no significant difference in LAM volume. Respectively, the mean total LAM volumes were 17.27 cm3 (SD = 3.97) and 17.04 cm3 (SD = 4.32), p = 0.79. The mean MLH measurements for both groups respectively were 10.06 cm2 (SD = 2.93) and 12.18 cm2 (SD = 2.93), indicating a significant difference (p = 0.01). POPQ analysis demonstrated statistically significant differences at Ba and Bp parameters suggesting that the DM group had worse prolapse (p = 0.05, 0.01, respectively). While LAM volumes are similar, there is a significant difference in the physical architecture of the LAM and the POPQ parameters in muscle-damaged patients compared to the normal group.

Exploring pelvic floor muscle activity in men with lower urinary tract symptoms.

AimWe aimed to explore the utility of the Multiple Array Probe Leiden (MAPLe) device to assess pelvic floor muscle activity in men with lower urinary tract symptoms (LUTS).MethodsThis was an observational cohort study performed at the urology outpatient department of a large teaching hospital in the Netherlands between April and October 2018. We recruited male patients referred for the assessment of LUTS, without a history of prostate surgery, if they had an International Prostate Symptom Score greater than or equal to 8. The MAPLe device was then used to assess the puborectalis, pubococcygeus, iliococcygeus, urogenital diaphragm, and the internal and external anal sphincters during three tasks: a rest period (1 minute), five maximum voluntary contractions (held for 3 seconds each), and three maximal endurance contractions (held for 15 seconds each).ResultsIn total, 57 patients were included, 5 of which had diabetes mellitus. Muscle activity at rest was significantly lower than during either contraction task and did not differ between the muscle groups. By contrast, the external anal sphincter had significantly less activity than any other muscle group during the endurance task, and the internal anal sphincter and puborectalis had significantly less activity during the maximum voluntary contraction task. No association was found between pelvic floor muscle activity and LUTS severity during any task.ConclusionPelvic floor muscle activity and LUTS severity appear to be unrelated, but this does not completely exclude the possibility of muscle involvement in the development or experience of symptoms. Further research is needed.

Morphological characteristic of anal canal in patients with dyssynergic defecation and its correlation with anorectal manometry

Objective: To evaluate the diagnostic value of three-dimensional endoanal ultrasound (3D-EAUS) for dyssynergic defecation (DD). Methods: A case-control study was performed to retrospectively collectclinical data of 46 DD patients, including 16 males and 30 females with median age of 51 (20 to 70) years, at Nanjing Hospital of Chinese Medicine from February 2012 to April 2015.All the patients met the diagnostic criteria of functional constipation of Rome III. The paradoxical contraction of puborectalis (PR) muscle was found by both rectal examination and anorectal manometry. In the same period,45 healthy volunteers, including 22 males and 23 females with median age of 48 (21 to 72) years, without pelvic operation history, and with normal defecation in recent 6 months, were enrolled as the control group. No significant differences were observed in age and gender between two groups (both P>0.05). Cleveland constipation score of DD group was higher than that of control group [15(8-24) vs. 5(1-9), t=15.720, P<0.001]. 3D-EAUS examination was performed in all the subjects. Thickness and length of internal anal sphincter (IAS) (anterior side and posterior side), thickness of PR muscle, length of external anal sphincter (EAS) plus PR muscle, and puborectalis angle were measured and compared by using student t test between two groups. Correlation between these ultrasound parameters and anorectal manometry was examined by Pearson correlation analysis. Results: Both male and female in the DD group had the greater thickness of IAS, as compared to those in the control group [male: (1.7±0.5) mm vs.(1.5±0.2) mm, t=2.516, P=0.016; female: (1.9±0.4) mm vs.(1.6±0.5) mm, t=2.034,P=0.047]. No significant differences between the two groups were observed with respect to the posterior length of IAS, length of EAS plus PR muscle, and thickness of PR muscle (all P>0.05). Compared to the control group, male in the DD group had smaller puborectalis angle during straining [(87.0±3.6)° vs. (90.5±1.8)°,t=3.502,P=0.002];female in the DD group had smaller puborectalis angle both in resting and straining [resting:(86.5±3.8)° vs. (90.1±2.1)°,t=4.047, P<0.001;straining: (84.1±4.5)° vs. (90.2±2.3)°, t=5.938, P<0.001]. Correlation analysis showed that anterior length of IAS was positively correlated with anal resting pressure (r=0.321, P=0.030); the length of EAS plus PR muscle was positively correlated with anal squeeze pressure (r=0.415, P=0.004). There were no correlations between the thickness and the posterior length of IAS and the anal resting pressure, or between the thickness of PR muscle and the anal squeeze pressure (all P>0.05). Conclusions: The 3D-EAUS can accurately assess the morphological features of anal canal in DD patients. There is a certain positive correlation between 3D-EAUS and anorectal manometry.

Clinical and MRI changes of puborectalis and iliococcygeus after a short period of intensive pelvic floor muscles training with or without instrumentation : A prospective randomized controlled trial.

This study evaluates the impact of a 3-week period of intensive pelvic floor muscles training (PFMT), with or without instrumentation, on clinical and static magnetic resonance imaging (MRI) changes of puborectalis (PR) and iliococcygeus (IL) muscles. 24 healthy young women were enrolled in the study and 17 achieved the 9 sessions of 30 min training exercises and conducted all assessments. Participants were randomly assigned in two training groups: voluntary contractions combined with hypopressive exercises (HYPO) or biofeedback exercises combined with transvaginal electrical stimulations (ELEC). Clinical and T2-weighted MRI assessments were realized before and after training. Modified Oxford Grading System (MOGS) scores for left PR and perineal body significantly increased in the two groups (p = 0.039, p = 0.008), but MOGS score for right PR significantly increased only in HYPO (p = 0.020). Muscle volumes of right and left IL significantly decreased (p = 0.040, p = 0.045) after training as well as signal intensities of right and left PR (p = 0.040, p = 0.021) and thickness of right and left IL at mid-vagina location (p = 0.012, p = 0.011). A short period of intensive PFMT induces clinical and morphological changes in PFMs at rest suggesting a decrease in IL volume and adipose content of PR. Although the results suggested that an intensive non-instrumented PFMT is as effective as an instrumented training, future controlled studies with greater sample sizes are needed to establish the relative and absolute effectiveness of each of the two interventions.

Three-Dimensional Anorectal Manometry Enhances Diagnostic Gain by Detecting Sphincter Defects and Puborectalis Pressure.

Constipation and fecal incontinence (FI) are common and are often evaluated with anorectal manometry. Three-dimensional high-resolution anorectal manometry (HRAM) is a promising technology; however, implementation has been limited by lack of metrics and unclear clinical utility. To investigate the diagnostic utility of 3D HRAM compared to 2D HRAM. Three-dimensional HRAM studies performed from April 2012 to October 2013 were identified and re-interpreted by two blinded investigators examining 3D function. Disagreements were resolved by a third investigator. Puborectalis (PR) visualization, focal defects, and dyssynergy were reported. Differences between groups were analyzed with Fisher's exact test. Discordance was analyzed with McNemar Chi-square test. Two hundred and twenty-one 3D HRAM studies were identified. Mean age and BMI were 52.2±17.4 and 27.1±7.5years (81% female, 74% white). Most common indications for 3D HRAM were constipation (65%) and FI (28%). PR function was visualized in 81% (rest), 97% (squeeze), and 73% (strain). PR was visualized less often at rest in FI than constipation (68 vs. 85%, p=0.007). Defects were identified twice as often in FI than constipation (19 vs. 10%, p=0.113). Twenty-nine defects (86% anterior) were visualized on 3D HRAM. Inter-reader agreement was moderate for PR function (κ=0.471), but fair for focal defects (κ=0.304). PR function and focal defects can be visualized on 3D-HRAM with added diagnostic benefit compared to 2D. Fair inter-reader agreement for focal defects highlights the need for quantitative metrics.

Evaluation of sphincter damage degree with anal endosonography for children with fecal incontinence

To evaluate the application of anal endosonography in the morphology of internal anal sphincter (IAS), external anal sphincter (EAS) and puborectalis (PR) in order to provide necessary information for analysis of the etiology of fecal incontinence and formulation of the therapeutic schedule. From December 2010 to November 2012, 18 children of anorectal malformation (n=14) or Hirschsprung's disease(n=4) with fecal incontinence received anal endosonography. The morphology of IAS, EAS and PR was observed. The damage of anal sphincter was classified according to Starck criteria. Anorectal mamometry and anal clinical score were measured simultaneously. Spearman analysis was performed to examine the correlation of anal sphincter damage with anorectal mamometric score and anal clinical score. According to Starck criteria, anal sphincter damage was small in 11 children, moderate in 6, and severe in 1. PR damage was found in 4 cases. Starck score was positively correlated with manometric score(P<0.05), while not correlated with anal clinical score(P>0.05). Anal endosonography can clearly display the morphology of IAS, EAS and PR, and their integrity and damage degree. It is a very valuable technique to evaluate the anal sphincter of the children with fecal incontinence, which however can not reflect the function of anal sphincter and anal continence thoroughly.

Interrater reliability of assessing levator ani deficiency with 360° 3D endovaginal ultrasound

Three-dimensional endovaginal ultrasound has been used for evaluation of levator ani muscle deficiency. The aim of this study was to assess interrater agreement/reliability of 3D endovaginal ultrasound for scoring levator ani deficiency (LAD). This was a cross-sectional study. Women referred to our urogynecology clinic for different pelvic floor dysfunction symptoms during November 2010-November 2012 were recruited. All patients underwent physical examination, including Pelvic Organ Prolapse Quantification (POP-Q) examination and high-resolution 3D endovaginal ultrasound. The levator muscle was divided into three subgroups based on our prior work: the puboperinealis/puboanalis (PA), puborectalis (PR), and iliococcygeus/pubococcygeus (PV). Subgroups were evaluated in their specific axial plane and were scored according to thickness and detachment from the pubic bone. Scoring was conducted by four raters blinded to case status and to one another's scores. Ninety patients were recruited. The median age was 52 (range 24-86). Median body mass index (BMI) was 28.08 (range 17.08-51.39). Fifty percent of patients were menopausal. The range of exact agreement for total LAD score was 77-90 %. All the correlation coefficients at the individual sites as well as the overall scores were positive at above 0.63 and significant at <0.0001 level. Our study demonstrates excellent agreement between raters assessing levator ani muscle deficiency using 3D endovaginal ultrasound. This level of concordance supports the reliability of the 3D endovaginal ultrasound technique and scoring method among raters [corrected].

Is Intraoperative Anal Endosonography Necessary During Laparoscopy-Assisted Anorectoplasty for High/Intermediate Type Imperforate Anus?

The aim of this study was to evaluate the relevance of anal endosonography (AES) during Georgeson laparoscopy-assisted anorectoplasty (GLA) for high/intermediate type imperforate anus (HIIA) using a continence evaluation questionnaire (CEQ) and postoperative AES (post-AES). Fifteen HIIA patients who underwent GLA were enrolled in this prospective study. Six had intraoperative AES (op-AES) to confirm the accuracy of the positioning of the pull-through (PT) canal and 9 did not (no-AES). All subjects were reviewed prospectively by one surgeon and all had post-AES to measure the external sphincter (ES) and puborectalis (PR) at 3 and 9 o'clock to confirm that the PT colon was central. A CEQ (5 parameters: frequency of motions, severity of staining, severity of perianal erosions, anal shape, and requirement for medications; maximum score: 10) was administered to 9 subjects (4 from op-AES and 5 from no-AES) followed-up for over 3 years to assess continence. Mean age at GLA for both groups was not statistically different. There were no statistical differences between the two groups for thickness of the ES and PR on post-AES. Mean annual CEQ scores for the op-AES group 1, 2, 3, 4, and 5 years after GLA were 5.3, 6.3, 7.4, 8.4, and 8.5, respectively, while for the no-AES group were 5.9, 7.1, 8.1, 8.2, and 8.2, respectively; all differences were not statistically significant. Our results suggest that op-AES is not necessary during GLA because there is no difference in clinical and functional status that can be attributed to op-AES.

Midterm postoperative clinicoradiologic analysis of surgery for high/intermediate-type imperforate anus: prospective comparative study between laparoscopy-assisted and posterior sagittal anorectoplasty

The objective of this study is to analyze the outcome of surgery for high/intermediate-type imperforate anus using anal endosonography (AES), magnetic resonance imaging (MRI), and a continence evaluation questionnaire (CEQ). In this study, 24 cases of high/intermediate-type imperforate anus were studied. Fifteen of 24 had Georgeson's laparoscopy-assisted anorectoplasty (GLA), and 9 of 24 had Pena's posterior sagittal anorectoplasty (PPA). All subjects had AES and MRI postoperatively. On AES, differences in thickness of the external sphincter (ES) and puborectalis (PR) at 3 and 9 o'clock were compared, and if pull-through colon was central, AES was 0. On MRI, differences in thickness were analyzed semiquantitatively and scored; if muscles were of even thickness, the score was 0; slight difference was 1, and marked difference was 2. A 5-parameter CEQ questionnaire (maximum score, 10) was administered to 16 of 24 subjects followed up for more than 3 years (9 GLA, 7 PPA). Surgical stress was assessed using mean febrile period, duration of raised white blood cell count, and peak C-reactive protein level. Mean age at surgery and mean postoperative period for both groups were not statistically different. There were no differences in mean muscle thickness for ES or PR on AES according to procedure (ES: GLA = 0.19 +/- 0.15 mm, PPA = 0.16 +/- 0.09 mm, P = .59; PR: GLA = 0.19 +/- 0.19 mm, PPA = 0.22 +/- 0.15 mm, P = .69). Magnetic resonance imaging scores were also not significantly different according to procedure (GLA: 0.77 +/- 0.83; PPA: 0.75 +/- 0.50, P = .97). When CEQ were compared annually, scores for GLA were generally higher throughout the study but only statistically significant at 3 and 4 years (P < .05). Differences in parameters of surgical stress were not significant. Although there were no differences in muscle thickness and parameters of surgical stress observed according to technique, GLA would appear to provide better outcome based on CEQ scores.

Racial differences in pelvic floor muscle thickness in asymptomatic nulliparas as seen on magnetic resonance imaging–based three-dimensional color thickness mapping

The objective of the study was to compare levator and obturator thickness between asymptomatic black and white nulliparas using three-dimensional (3D) magnetic resonance imaging (MRI) color mapping. 3D color-mapped MRI of pelvic muscles were evaluated in 22 similar nulliparas (12 black, 10 white). Levator and obturator (OI) were divided into right and left. Levator was subdivided into puborectalis (PR) and ileococcygeus (IC) portions. Maximal thickness of each muscle was recorded and compared between groups. Nonparametric testing was applied, with significance at P = .05. Levator thickness was significantly greater in blacks bilaterally (median right PR, 8.5 vs 6.0 mm; P = .001; right IC, 6.5 vs 4.5 mm; P = .002; left PR, 9.5 vs 5.75 mm; P = .0002; left IC, 6.5 vs 5.75 mm; P = .02). Obturator thicknesses were similar (right OI, 20.0 vs 19.5 mm; left OI, 19.25 vs 19.25 mm; P = NS). Significantly thicker levators but similar obturators were seen in black nulliparas, compared with white nulliparas. These levator differences may influence pelvic floor dysfunction risk. The clinical significance of these findings is under study.

Image analysis of puborectalis syndrome and its clinical significance

To discuss the clinical value and application range of defecography, CT and MRI in diagnosis of puborectalis syndrome (PRS). The clinical data of 83 PRS patients, including defecography, CT and MRI scanning in pelvic floor resting and defecation at maximum exertion, measurement of anorectal angle (ARA), length and depth of ARA impression and the thickness of the puborectalis muscle, were collected, and compared with those of 56 normal persons. For normal persons, ARA at maximum exertion was more significantly increased than that at resting. In 62 cases with PRS, ARA at maximum exertion was more obviously reduced than that at resting and associated with puborectalis muscle (PRM) impression. In the other 21 cases, ARA showed no changes at either maximum exertion or resting, a little or no excretion of barium appeared and "shelving syndrome" was showed. The cross-sectional images of CT and MRI showed that the puborectalis of PRS patients were thicker than that of normal persons (P<0.01). PRS patients also showed clear pelvic floor muscle, fasciae and peripheral crevice. Defecography, manifested the abnormal function of the puborectalis muscles, is a reliable method for diagnosis of PRS. In the meantime, CT and MRI are able to clearly display the position, growth status and size of the puborectalis muscles as well as its relation with adjacent structures, which provide further understandings on anatomical changes, abnormal adjacent structure and other functional diseases of pelvic floor in PRS patients. Therefore, an appropriate combination of the 3 methods play an important role in the early diagnosis of PRS and guidance for surgical treatment.

Intraoperative Endosonographic Assessment of Pelvic Floor Muscles during Laparoscopy-Assisted Colon Pull-through for High Imperforate Anus

Purpose: To use endosonography to assess the components and lengths of the pelvic floor muscles (PFM) in patients with high imperforate anus (HIA) during laparoscopy-assisted colon pull-through (LACPT). Methods: Three male infants (Nos. 1, 2, and 3) with HIA and rectourethral fistula were examined. A proctoscopic ultrasonography probe (7.5 MHz, 12 mm in diameter) was inserted along the course of the proposed pull-through canal under laparoscopic control to assess the structure and thickness of the main components of the PFM - that is, the pubococcygeus (PC), puborectalis (PR), muscle complex (MC), and external sphincter (ES) - and measure the length of the entire PFM. Results: Weight at LACPT was 8.0 kg in No. 1, 5.9 kg in No. 2, and 8.5 kg in No. 3. In all cases, the proposed pull-through canal lay centrally within the PFM on endosonography. The length of the PFM was 42 mm in No. 1, 31 mm in No. 2, and 39 mm in No. 3. Conclusion: Intraoperative endosonography during LACPT permitted examination of the PFM...

Study of the pelvic floor muscles in vaginismus: a concept of pathogenesis

Background: Neither the cause of vaginismus nor the muscles involved are precisely identified. Aim: To define the involved muscles and their role in the pathogenesis of vaginismus. Methods: The EMG activity of the levator ani (LA), puborectalis (PR) and bulbocavernosus (BC) muscles was studied in seven female patients (age (years): 25.6 ( mean)±1.2 ( S.D.) ) and seven healthy volunteers who matched the patients in age. Recordings were performed at rest and during induction of vaginismus by a vaginal dilator. Main results: Upon approximating the vaginal dilator to the vaginal introitus or introducing it into the vagina of the healthy volunteers, the EMG activity of the LA, PR and BC muscles showed no significant difference from the basal activity. In the patients, the basal EMG activity of the examined muscles was significantly higher than that of the healthy volunteers ( P<0.05). Upon vaginismus induction, the muscles showed a significant increase of the EMG activity ( P<0.01). The latency recorded a mean of 14.2±2.3, 13.9±2.3 and 14.1±2.2 ms ( P>0.05) in the LA, PR and BC muscles, respectively. The muscle response was momentary lasting a mean of 31.2±5.7 s. It was reproducible provided an off-time of a mean of 13.2±2.3 s was observed. Conclusion: The pelvic floor muscles of vaginismus patients exhibited increased EMG activity at rest and on vaginismus induction; the cause is unknown. The concept of a disordered sacral reflex arc is put forward but needs further studies to be verified.

Effect of pelvic floor muscle contraction on vesical and rectal function with identification of puborectalis-rectovesical inhibitory reflex and levator-rectovesical excitatory reflex

The effects of pelvic floor muscle contraction on rectal and vesical function were studied in 19 healthy volunteers with the aim of shedding light on some of the hitherto vague aspects of the mechanisms involved in micturition and defecation and their disorders. Rectal and vesical pressures were recorded during puborectalis (PR) and levator ani (LA) muscle stimulation with the rectum or urinary bladder empty and full. Muscle stimulation was effected by needle EMG electrode. The pressure responses to stimulation of the PR and LA muscles were also recorded with these muscles and the rectum and urinary bladder individually anesthetized in 12 of the 19 subjects. The test was repeated using saline instead of xylocaine. PR and LA muscle stimulation produced no pressure response in the empty rectum or bladder. Upon rectal balloon distension with a mean of 156.6+/-34.2 ml of carbon dioxide the mean rectal pressure was 64.6+/-18.7 cm H2O, the subject felt the urge to evacuate and the balloon was expelled to the exterior. On PR muscle stimulation at rectal distension with the above volume, the subject did not feel the urge to evacuate, the rectal pressure was 8.2+/-1.6 cm H2O and the balloon was not expelled. Upon LA stimulation at the same volume, the urge persisted, the rectal pressure was higher and the balloon was expelled. Vesical filling with a mean of 378.2+/-23.6 ml of saline initiated the urge to urinate and elevated the vesical pressure. PR muscle stimulation at this volume aborted the urge and pressure elevation, while LA stimulation caused more elevation of the vesical pressure and spontaneous micturition. Bladder filling with a mean of 423.6+/-38.2 ml produced high vesical pressure and spontaneous urination, both of which were prevented by PR muscle stimulation but not by LA muscle stimulation. Stimulation of the PR and LA muscles during individual anesthetization of the rectum, bladder or PR and LA muscles resulted in no significant rectal or vesical pressure changes. Repetition of the test using saline instead of xylocaine resulted in rectal and vesical pressure responses similar to those without the use of saline. In conclusion, the decline in rectal and vesical responses upon PR muscle contraction indicates a reflex relationship which we term 'puborectalis rectovesical inhibitory reflex'. This reflex is suggested to abort the urge to defecate or urinate. In contrast, LA muscle contraction produced rectal and vesical pressure elevation which is suggested to be mediated through the 'levator rectovesical excitatory reflex'. 'This reflex is probably evoked to promote rectal and vesical evacuation.

Cervico‐motor reflex: Description of the reflex and role in sexual acts

A recently identified reflex, termed the “cervico‐motor reflex,” was studied in 15 healthy women (mean age 36.6 years). The response of levator ani (LA) and puborectalis (PR) muscles to electrical and mechanical stimulation of the cervix uteri (CU) was determined. One concentric needle electrode was inserted into the CU (stimulating), a second into the LA (recording), and a third into the PR (recording). The vaginal pressure was measured at rest and on cervical stimulation by balloon‐tipped catheters. Electrical stimulation of the CU led to a reduction in pressure in the upper portion of the vagina (p < .05) and an increase in pressure in the middle and lower portions (p < .001). Stimulation also caused an increase in the electromyographic (EMG) activity of the LA and PR muscles (p < .01). Mechanical stimulation induced the same effects but to a lesser degree. Stimulation of the anesthetized CU, LA, or PR did not evoke the response. The data suggested the presence of a reproducible reflex relationship bet...

The ‘clitoromotor’ reflex

The effect of glans clitoris (GC) stimulation on the vagina, uterus and pelvic floor muscles (levator ani (LA) or pubococcygeus, puborectalis (PR)) was studied in 16 healthy volunteers (mean age 34.9 years). The GC was stimulated mechanically and electrically while recording the vaginal and uterine pressures and the electromyographic activity of PR and LA. Stimulation caused a drop in the uterine (P<0.001) and upper vaginal (P<0.05) pressures (1.6 and 2.9 cmH2O, respectively) and an increase in the middle (P<0.001) and lower (P<0.001) vaginal pressures (58.6 and 89.2 cmH2O, respectively). It also effected an increase of EMG activity in the PR (P<0.01) and LA (P<0.01). Response was greater with electrical than with mechanical stimulation (P<0.05). No response occurred upon stimulation of the anesthetized GC or the anesthetized PR or LA. The reproducibility of the PR and LA contraction on GC stimulation postulates a reflex relationship which we call the ‘clitoromotor reflex’. This induces uterovaginal changes that enhance the sexual response of both partners, and also prepares the uterus and vagina for the reproductive process. LA contraction pulls open and reduces the pressure in the upper vagina as well as elevating the cervix uteri. PR contraction constricts the middle and lower vagina and increases their pressure.

Cinedefecography and electromyography in the diagnosis of nonrelaxing puborectalis syndrome.

A prospective study was undertaken to assess the correlation between electromyography (EMG) and cinedefecography (CD) for the diagnosis of nonrelaxing puborectalis syndrome (NRPR). Clinical criteria for NRPR included straining, incomplete evacuation, tenesmus, and the need for enemas, suppositories, or digitation. EMG criteria included failure to achieve a significant decrease in electrical activity of the puborectalis (PR) during attempted evacuation. CD criteria included either paradoxical contraction or failure of relaxation of the PR along with incomplete evacuation. In addition, other etiologies for incomplete evacuation, such as rectoanal intussusception or nonemptying rectocele, were excluded by proctoscopy and defecography in all cases. One hundred twelve patients with constipation, 81 females and 31 males, with a mean age of 59 (range, 12-83) years were studied by routine office evaluation, CD, and EMG. Forty-two patients (37 percent) had evidence of NRPR on CD (rectal emptying: none, 24; incomplete, 18). Twenty-eight of these patients (67 percent) also had evidence of NRPR on EMG. EMG findings of NRPR were present in 12 of 70 patients (17 percent) with normal rectal emptying. Conversely, 14 of 72 patients (19 percent) with normal PR relaxation on EMG had an NRPR pattern on CD. The sensitivity and specificity for the EMG diagnosis of NRPR were 67 percent and 83 percent, and the positive and negative predictive values were 70 percent and 80 percent, respectively. Conversely, if EMG is considered as the ideal test for the diagnosis of NRPR, CD had a sensitivity of 70 percent, a specificity of 80 percent, and positive and negative predictive values of 66 percent and 82 percent, respectively. In summary, sensitivity, specificity, and predictive values of EMG and CD are suboptimal. Therefore, a combination of these two tests is suggested for the diagnosis of NRPR.