Rectal Intussusception Research Articles

Pelvic floor ultrasound: Essentials

Female pelvic floor dysfunction encompasses a number of prevalent conditions and includes pelvic organ prolapse, urinary and fecal incontinence, obstructed defecation and sexual dysfunction. In most cases neither etiology nor pathophysiology are well understood. Imaging has great potential to enhance both research and clinical management capabilities, and to date this potential is under-utilised. Of the available techniques such as X-ray, computed tomography, magnetic resonance imaging and ultrasound, the latter is generally superior for pelvic floor imaging, especially in the form of perineal or translabial imaging. The technique is safe, simple, cheap, easily accessible and provides high spatial and temporal resolutions. The commonest indication for pelvic floor imaging is female pelvic organ prolapse. Translabial realtime ultrasound during a Valsalva maneuver will demonstrate cystocele, uterine prolapse, rectocele, enterocele and rectal intussusception and allow quantification against the inferoposterior symphyseal margin. The introduction of 3D/4D imaging has allowed us to diagnose major pelvic floor trauma (‘avulsion’) and overdistension of the levator hiatus (‘ballooning’) reliably and accurately. Both are major etiological factors in the pathogenesis of pelvic organ prolapse and can be detected using equipment that is commonly available in O/G imaging departments. Women with avulsion and/ or major degrees of hiatal overdistension are at an increased risk of prolapse recurrence after reconstructive surgery. Identifying such pathology will not just allow a more realistic discussion of operative options, especially as regards mesh use, but has already opened up opportunities for entirely novel surgical approaches such as levator reconstruction and hiatal reduction. Most recently, translabial 4D imaging of the anal sphincter has made the assessment of anal incontinence simpler and less invasive. This technique will allow universal audits of of OASIS repair and eventually of obstetric management in general, enabling the introduction of ‘maternal birth trauma’ as a key performance indicator of obstetric services.

Rectal intussusception and external rectal prolapse are common at proctography in patients with mucus discharge.

Objectives: Although various pelvic floor abnormalities are recognized to cause mucus discharge (MD), little is known about the exact distribution and frequency of diseases causing MD in evacuatory disorders. This study aimed to identify the most common diseases at evacuation proctography in patients with MD. Methods: Patients seen with symptoms of evacuatory disorder underwent proctography. Data for patients with MD who were not associated with fecal incontinence (FI) were prospectively entered into a database and analyzed retrospectively. The degree of MD was documented using FI Severity Index. Results: Sixty-two patients were included for analysis. Forty-nine (79%) had rectal intussusception (RI) or external rectal prolapse (ERP). Of those with RI, MD was observed more in patients with recto-anal intussusception (n = 22) than those with recto-rectal intussusception (n = 8). Of the 39 patients who were not associated with hemorrhoids or mucosal prolapse, 31 (79%) had RI or ERP. Meanwhile, of 582 patients who underwent proctography, 301 had RI and 96 had ERP. MD without FI was present in 13% (40/301) patients with RI and 9% (9/96) with ERP. Surgery was performed in 21 patients, and MD was cured in 20 (95%) postoperatively. Conclusions: RI and ERP were common at proctography in patients with MD.

Rectoanal intussusception is very common in patients with fecal incontinence.

Objectives: Fecal incontinence (FI) is a multifactorial disorder, the etiology of which is not fully understood. Recent data have shown the significance of rectoanal intussusception (RAI) in the evaluation of FI. The present study aimed to determine the incidence of RAI in patients with FI. Methods: Between June 2010 and February 2016, 74 patients, who were evaluated using evacuation proctography, anorectal manometry, ultrasound, and incontinence scores, were included in this study. RAI was diagnosed when the apex of the rectal intussusception (RI) impinged on the internal anal orifice or was intra-anal, based on the images taken during maximal straining defecation at evacuation proctography. The characteristics of RAI patients were further analyzed. Results: There were 59 women (80%) and 15 men, with a median age of 74 (52-93) years. Sixty patients (81%) had RI, and 56 (76%) showed RAI. The incidence of RAI among the 32 patients with FI alone and the 42 patients with FI and symptoms of obstructed defecation (OD) was 72% (23/32) and 79% (33/42), respectively. The incidence of RAI was not significantly different between the patients with normal manometry (maximum resting pressure [MRP] ≥55 cmH2O and maximum squeeze pressure [MSP] ≥150 cmH2O, n=26) and those with subnormal manometry (MRP <55 cmH2O and/or MSP <150 cmH2O, n=48). Conclusion: RAI is common in patients with FI. Evacuation proctography should be taken into account as a part of the regular study of FI patients.

The extracellular matrix glycoprotein tenascin-X regulates peripheral sensory and motor neurones.

Key points Tenascin‐X (TNX) is an extracellular matrix glycoprotein with anti‐adhesive properties in skin and joints. Here we report the novel finding that TNX is expressed in human and mouse gut tissue where it is exclusive to specific subpopulations of neurones.Our studies with TNX‐deficient mice show impaired defecation and neural control of distal colonic motility that can be rescued with a 5‐HT4 receptor agonist. However, colonic secretion is unchanged. They are also susceptible to internal rectal intussusception. Colonic afferent sensitivity is increased in TNX‐deficient mice. Correspondingly, there is increased density of and sensitivity of putative nociceptive fibres in TNX‐deficient mucosa.A group of TNX‐deficient patients report symptoms highly consistent with those in the mouse model.These findings suggest TNX plays entirely different roles in gut to non‐visceral tissues – firstly a role in enteric motor neurones and secondly a role influencing nociceptive sensory neuronesStudying further the mechanisms by which TNX influences neuronal function will lead to new targets for future treatment. The extracellular matrix (ECM) is not only an integral structural molecule, but is also critical for a wide range of cellular functions. The glycoprotein tenascin‐X (TNX) predominates in the ECM of tissues like skin and regulates tissue structure through anti‐adhesive interactions with collagen. Monogenic TNX deficiency causes painful joint hypermobility and skin hyperelasticity, symptoms characteristic of hypermobility Ehlers Danlos syndrome (hEDS). hEDS patients also report consistently increased visceral pain and gastrointestinal (GI) dysfunction. We investigated whether there is a direct link between TNX deficiency and GI pain or motor dysfunction. We set out first to learn where TNX is expressed in human and mouse, then determine how GI function, specifically in the colon, is disordered in TNX‐deficient mice and humans of either sex. In human and mouse tissue, TNX was predominantly associated with cholinergic colonic enteric neurones, which are involved in motor control. TNX was absent from extrinsic nociceptive peptidergic neurones. TNX‐deficient mice had internal rectal prolapse and a loss of distal colonic contractility which could be rescued by prokinetic drug treatment. TNX‐deficient patients reported increased sensory and motor GI symptoms including abdominal pain and constipation compared to controls. Despite absence of TNX from nociceptive colonic neurones, neuronal sprouting and hyper‐responsiveness to colonic distension was observed in the TNX‐deficient mice. We conclude that ECM molecules are not merely support structures but an integral part of the microenvironment particularly for specific populations of colonic motor neurones where TNX exerts functional influences.

Clinical outcomes of stapled transanal rectal resection for obstructed defaecation syndrome at 10-year follow-up.

The long-term efficacy of stapled transanal rectal resection (STARR) for surgical management of obstructed defaecation syndrome (ODS) has not been evaluated. Therefore, we investigated the long-term efficacy (>10years) of STARR for treatment of ODS related to rectocele or rectal intussusception and the factors that predict treatment outcome. This study was a retrospective cohort analysis conducted on prospectively collected data. Seventy-four consecutive patients who underwent STARR for ODS between January 2005 and December 2006 in two Italian hospitals were included. Seventy-four patients [66 women; median age 61 (29-77) years] underwent STARR for ODS. No serious postoperative complications were recorded. Ten years postoperatively, 60 (81%) patients completed the expected follow-up. Twenty-three patients (38%) reported persistent perineal pain and 13 (22%) experienced the urge to defaecate. ODS symptoms recurred in 24 (40%) patients after 10years. At the 10-year follow-up, 35% of patients were very satisfied and 28% would recommend STARR and undergo the same procedure again if necessary. In contrast, 21% of patients would not select STARR again. Previous uro-gynaecological or rectal surgery and high constipation scores were identified as risk factors for recurrence. Stapled transanal rectal resection significantly improves the symptoms of ODS in the short term. In the long term STARR is less effective, however.

Role of MR Defecography in the Assessment of Obstructed Defecation Syndrome

AbstractBackground: Obstructed Defecation Syndrome (ODS) is characterized by the urge to defecate but an impaired ability to expel the fecal bolus. Symptoms include unsuccessful fecal evacuation attempts, excessive straining, pain, bleeding after defecation, and a sense of incomplete fecal evacuation. ODS has been linked to anatomic abnormalities of rectocele, rec-toanal or recto-rectal intussusception, paradoxical puborectalis contraction, pelvic organ prolapse, descending perineum syndrome, solitary rectal ulcer syndrome, sigmoidocele, and enterocele. A functional abnormality such as pelvic floor dyssynergia, decreased rectal compliance and decreased rectal sensation has also been shown to contribute to symptoms of ODS.Objective: To assess the role of MR defecography in finding functional abnormalities in patients with obstructed defecation syndrome.Patients and Methods: A prospective study was carried out on 30 patients (20 females and 10 males) with clinical symptoms of obstructed defecation syndrome for a period longer than 6 months. Patients were assessed statically using T2 weighted images and dynamically by MR defecography using fast imaging via steady-state acquisition sequences. All patients had symptoms of obstructed defecation syndrome as unsuccessful fecal evacuation attempts, excessive straining, pain during defecation, a sense of incomplete fecal evacuation and digital rectal evacuation.Results: A total of 30 patients with a mean age of 40.2 with 20 (66.7%) females and 10 (33.3%) males. MR defecog-raphy revealed rectocele in 19 (63.3%) of all patients and cystocele in 17 (56.7%) patients. Four patients (13.3%) had rectal intussusception. Spastic pelvic floor syndrome was found in 2 patients (6.75%). Multicompartmental dysfunction was observed in 18 (60%) of the female patients.Conclusion: MR defecography was proven to be highly valuable in assessing patients with obstructed defecation syndrome, particularly females as it depicts multicompart-mental dysfunction in females with a seemingly single com-partment symptom ultimately changing the treatment approach.

Diagnosis and Treatment of Rectal Intussusception

Diagnosis and Treatment of Rectal Intussusception

Treatment of obstructed defecation syndrome due to rectocele and rectal intussusception with a high volume stapler (TST STARR-plus).

In recent years, stapled transanal resection (STARR) has been adopted worldwide with convincing short-term results. However, due to the high recurrence rate and some major complications after STARR, there is still controversy about when the procedure is indicated. The aim of this study was to assess the safety, efficacy and feasibility of STARR performed with a new dedicated device for tailored transanal stapled surgery. All the consecutive patients affected by obstructed defecation syndrome (ODS) due to rectocele or/and rectal intussusception, who underwent STARR with the TST STARR-Plus stapler, were included in a prospective study. Pain, Cleveland Clinic Score for Constipation (CCCS) and incontinence, patient satisfaction, number of hemostatic stitches, operative time, hospital stay and perioperative complications were recorded. Postoperative complications and recurrence were also reported. Forty-five consecutive patients (median age 50; range 24-79) were included in the study. Median resected volume was 15cm3 (range 12-19cm3) with a median height of surgical specimen of 5.6cm (range 4.5-10cm). The mean CCCS decreased from 17.26 (±3.77) to 5.42 (±2.78) postoperatively (p<0.001). Patient satisfaction grade was excellent in 14 patients (31.1%), good in 25 (55.5%), sufficient in three (6.7%) and poor in three patients (6.7%). No major complications occurred. Five patients (11%) reported urgency after 30days and two patients (4%) after 12months. The Cleveland Clinic Incontinence score did not significantly change. At a median follow-up of 23months (range 12-30months), only three patients (6.7%) reported recurrent symptoms of obstructed defecation comparable to those reported at baseline. TST STARR-Plus seems to be safe and effective for the treatment of ODS due to rectocele and rectal intussusception, and technical improvement could reduce the risk of some complications. However, careful patient selection is still the best means of preventing complications.

Surgery for constipation: systematic review and practice recommendations

To assess the outcomes of rectal suspension procedures (forms of rectopexy) in adults with chronic constipation. Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements with a summative Oxford Centre for Evidence-Based Medicine (2009) level. Eighteen articles were identified, providing data on outcomes in 1238 patients. All studies reported only on laparoscopic approaches. Length of procedures ranged between 1.5 to 3.5h, and length of stay between 4 to 5days. Data on harms were inconsistently reported and heterogeneous, making estimates of harm tentative and imprecise. Morbidity rates ranged between 5-15%, with mesh complications accounting for 0.5% of patients overall. No mortality was reported after any procedures in a total of 1044 patients. Although inconsistently reported, good or satisfactory outcome occurred in 83% (74-91%) of patients; 86% (20-97%) of patients reported improvements in constipation after laparoscopic ventral mesh rectopexy (LVMR). About 2-7% of patients developed anatomical recurrence. Patient selection was inconsistently documented. As most common indication, high grade rectal intussusception was corrected in 80-100% of cases after robotic or LVMR. Healing of prolapse-associated solitary rectal ulcer syndrome occurred in around 80% of patients after LVMR. Evidence supporting rectal suspension procedures is currently derived from poor quality studies. Methodologically robust trials are needed to inform future clinical decision making.

FUNCTIONAL STATE OF THE PELVIC FLOOR MUSCLES IN PATIENTS WITH THE PELVIC PROLAPSE

The article analyzes the functional state (evacuation functions, continence) and innervation of the pelvic floor muscles in patients with rectocele and combination rectocele with internal rectal intussusception, with complaints of obstructive defecation. AIM. The study of the functional state of the pelvic floor muscles in patients with obstructive defecation syndrome (ODS). MATERIALS AND METHODS. The study included 224 women with complaints of obstructive defecation, without pelvic floor surgery. On physical examination, all patients were detected signs of rectocele. The average age - 49,9±15,0 years. 52 (23,2%) patients had complaints to the fecal incontinence of various components. Diagnostic algorithm: physical examination defecography, rectal functional study (high resolution manometry (HRAM), evacuation test, comprehensive sphincterometry, pudendal nerve study). RESULTS. Frequency of functional disorders of defecation (FDD) according to objective methods of study among patients with ODS is high and amounts to 64.7%. In this case, there are no differences in the frequency FDD in patients with a combination of rectocele and internal intussusception compared to patients with only rectocele. There were no correlation between the frequency of anal sphincter failure and FDD. We identified some patients with subclinical incontinence, without complaints but with reduced manometric values and anal sphincter contractility. We have proved the absence of correlation between the presence or absence of pelvic floor muscle innervations violations in the form of neuropathy n. pudendus and the presence or absence of FDD. CONCLUSION. FDD can cause unsatisfactory results of surgical treatment of patients with ODS, even after the restoration of the anatomic relationships due to complaints of evacuation violation. ODS diagnostic algorithm should include not only an assessment of evacuationfunction (HRAM and evacuation test), but also sphincterometry, to assess the content function.

Anal Sphincters Evaluation by Endoanal Ultrasound in Obstructed Defecation.

To evaluate anal sphincter abnormalities detected by endoanal ultrasound in obstructed defecation due to rectocele and rectal intussusception. The retrospective analysis includes 45 patients with obstructed defecation syndrome due to rectocele and/or rectal intussusception with or without fecal incontinence, and submitted to endoanal ultrasound. Ninety-three percent (n = 42) were women (mean age of 63 ± 12 years), and 47% (n = 21) of the patients had fecal incontinence. In total, 29% (n = 13) had a previous anorectal surgery, and 93% (n = 39) of the women had a previous vaginal delivery. An isolated rectal intussusception was diagnosed in 20% (n = 9) of the patients, an isolated rectocele in 24% (n = 11), and rectal intussusception and rectocele in 56% (n = 25). Thirty-six percent of patients had anal sphincter lacerations (n = 16): 12% (n = 2) had only internal laceration, 69% (n = 11) had only external laceration, and 19% (n = 3) had both. Two patients had a thinner internal anal sphincter with 0.9 and 1.2 mm, respectively. In total, 25% of the patients without fecal incontinence had an occult anal sphincter laceration, and all were women with an external sphincter laceration in the anterior quadrant and a previous vaginal delivery. In patients with obstructed defecation and fecal incontinence, 48% had sphincter lacerations. Previous anorectal surgery was a predictor of anal sphincter laceration (odds ratio [OR] 4.8; 95% confidence interval [CI] = 1.214-18.971; P = .025), but fecal incontinence (OR 2.7; 95% CI = 0.774-9.613; P = .119) and previous vaginal delivery (OR 1.250; 95% CI = 0.104-15.011; P = .860) were not. Endoanal ultrasound should be considered in obstructed defecation with or without fecal incontinence, especially if surgical correction is planned.

Stubborn rectal prolapse in systemic sclerosis.

Systemic sclerosis (SSc) is an autoimmune connective tissue disorder. Anorectal involvement might typically cause fecal incontinence and rarely rectal prolapse. Here we report three female patients, who were admitted with a mean history of 10 years suffering from SSc. All patients presented with the initial symptom of anal incontinence, in all cases this was associated with rectal intussusception or rectal prolapse. The three women faced prolapse recurrence, independent of the initial procedure. After surgical removal of the prolapse, the incontinence remained.In SSc rectal prolapse syndrome might occur at an earlier age, and a primary prolapse of the ventral aspect of the rectal wall seems to be typical for this disease. If patients with prior diagnosis of SSc appear with third degree of fecal incontinence, it is suspected to be associated with rectal prolapse. The prolapse recurrence rate after surgery in SSc patients is high.

The ‘bother’ of obstructed defecation

To examine the relationship of visual analog scale (VAS) 'bother' scores for obstructed defecation (OD) with demographic data, physical examination and sonographic findings of the posterior compartment. All patients seen at a urogynecology clinic between January and October 2013 were included. Patients were diagnosed with OD if they had any of the following: incomplete bowel emptying, straining with bowel movement or need for digitation. Patients used a VAS to rate OD bother on a scale of 0-10 (0, no bother; 10, worst imaginable bother). For each patient, a comprehensive history was obtained, the International Continence Society Pelvic Organ Prolapse Quantification was performed and four-dimensional translabial ultrasound volumes were recorded on maximal Valsalva maneuver. Linear and multiple regression models were used to correlate bother VAS scores with demographic, clinical and sonographic findings. Among 265 patients included in the analysis, 61% had OD symptoms with a mean VAS bother score of 5.6. OD bother scores were associated with a history of previous prolapse surgery (P = 0.0001), previous hysterectomy (P = 0.0006), descent of the posterior compartment (Bp; P = 0.004) and hiatal dimensions (Pb and Gh + Pb; P = 0.006 and P = 0.004). OD bother was associated with the following sonographic findings: true rectocele (P = 0.01), depth of rectocele (P = 0.04), descent of rectal ampulla (P = 0.02), enterocele (P = 0.03) and rectal intussusception (P < 0.0001). VAS bother scores are associated with both clinical and sonographic measures of posterior compartment descent. Rectal intussusception was most likely to result in highly bothersome symptoms of OD. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Surgical options for full-thickness rectal prolapse: current status and institutional choice.

Full-thickness rectal prolapse (FTRP) is generally believed to result from a sliding hernia through a pelvic fascial defect, or from rectal intussusception. The currently accepted cause is a pelvic floor disorder. Surgery is the only definitive treatment, although the ideal therapeutic option for FTRP has not been determined. Auffret reported the first FTRP surgery using a perineal approach in 1882, and rectopexy using conventional laparotomy was first described by Sudeck in 1922. Laparoscopy was first used by Bermann in 1992, and laparoscopic surgery is now used worldwide; robotic surgery was first described by Munz in 2004. Postoperative morbidity, mortality, and recurrence rates with FTRP surgery are an active research area and in this article we review previously documented surgeries and discuss the best approach for FTRP. We also introduce our institution’s laparoscopic surgical technique for FTRP (laparoscopic rectopexy with posterior wrap and peritoneal closure). Therapeutic decisions must be individualized to each patient, while the surgeon’s experience must also be considered.

2型上部直腸癌による成人腸重積の1例

2型上部直腸癌による成人腸重積の1例

Functional Disorders: Rectoanal Intussusception.

Rectoanal intussusception is an invagination of the rectal wall into the lumen of the rectum. Patients may present with constipation, incomplete evacuation, incontinence, or may be asymptomatic. Defecography has been the gold standard for detection. Magnetic resonance imaging defecography and dynamic anal endosonography are alternatives to conventional defecography. However, both methods are not as sensitive as conventional defecography. Treatment options range from conservative/medical treatment such as biofeedback to surgical procedures such as Delorme, rectopexy, and stapled transanal rectal resection. Recent studies conducted after a trial of failed nonoperative management show adequate results with operations performed for rectal intussusception with or without rectocele if other causes of constipation are not present.

TST36 stapling for rectocele and hemorrhoidal prolapse - early results of the prospective German multicenter study.

Introduction: The aim of the study was to evaluate the safety and feasibility of stapled transanal procedures performed by a 36 mm stapling device, the so-called TST36 stapler.Methods: From September 2013 to June 2014 a prospective observational study was carried out by 8 proctology centers in Germany. The Cleveland Clinic Incontinence Score (CCIS) for incontinence and the Altomare ODS score were determined preoperatively. Follow-up examinations were performed after 14 days, one month and 6 months, at this time both scores were reevaluated.Results: 110 consecutive patients (71 women, 39 men) with a mean age of 59.7 years (±13.8 years) were included in the study. The eight participating institutes entered 3 to 31 patients each into the study. The indication for surgery was an advanced hemorrhoidal disease in 55 patients and ODS with rectal intussusception or rectocele in 55 patients. Mechanical problems with stapler introduction occurred in 22 cases (20%) and a partial stapleline dehiscence in 4 cases (3.6%). Additional stitches for bleeding from stapleline were necessary in 86 patients (78.2%). Reintervention was necessary for bleeding 7 times (6.3%). Severe complications during follow-up were stapleline dehiscence in one case and recurrent hemorrhoidal prolapse in 5 cases (4.5%). Altomare ODS score and CCIS improved significantly after surgery.Conclusions: Despite a notable complication rate during surgery and the postoperative period, the TST36 can be considered as an effective tool for low rectal stapling for anorectal prolapse causing hemorrhoids or obstructed defecation.

Laparoscopic ventral mesh rectopexy in male patients with internal or external rectal prolapse.

Aim Laparoscopic ventral mesh rectopexy (LVMR) has been used to treat rectal prolapse, obstructed defaecation (OD), faecal incontinence (FI) and multicompartment pelvic floor dysfunction. Its value in treating men has been questioned. The aim of the present study was to assess the results in male patients. Method A password-protected electronic database of all LVMRs carried out in North Bristol NHS trust & Spire hospital between 2002 and 2013 was examined. In addition to the clinical outcome, quality of life (QoL), Cleveland Clinic Incontinence Score (CCIS), obstructed defecation syndrome (ODS) score, visual analogue score (VAS) for the severity of bowel and urinary symptoms and the numerical rating scale (NRS) for pain and patient-reported outcome measures were evaluated. Results Sixty-eight men of median age 35 years and body mass index 26 kg/m2 underwent LVMR for external rectal prolapse (18) or Grade III–V rectal intussusception (50) presenting with OD, FI and pelvic pain. Ten per cent had been labelled ‘chronic idiopathic pelvic pain’ and 60% had undergone previous haemorrhoidal surgery. Complications were minor and included urinary retention (10%). Eighty per cent of patients had an uncomplicated recovery with 24% being treated as day cases. There were no cases of impotence or retrograde ejaculation. Median follow-up was 42 (IQR 26–61) months. CCIS score improved from 4 (IQR 0–8) to 0 (IQR 0–0) (P < 0.001) and the ODS score from 18.5 (IQR 16–22) to 6 (IQR 5–8) (P < 0.001). Patients reported significant improvement in the NRS for pain and QoL (BBSQ-22) at 3 months (P = 0.000). The QoL and the VAS for bowel symptoms were maintained at 4 years. At the last follow-up 56 (82%) patients were asymptomatic and 6 (8.8%) had persisting symptoms. There was no case of recurrent external rectal prolapse. Conclusion LVMR is an effective treatment for external and symptomatic internal rectal prolapse in men, leading to significant improvement in QoL and function.

Rectal intussusception: can high resolution three-dimensional ano-rectal manometry compete with conventional defecography?

Three-dimensional high-resolution anorectal manometry (3DHRAM), used for exploring anorectal disorders, was recently developed, providing interesting topographic data for the diagnosis of pelvic floor disorders such as excessive perineal descent. The aim of our study was to define a diagnostic strategy based on selected 3DHRAM parameters to identify rectal intussusceptions (RI), considering conventional defecography (CD) as the gold standard. All patients referred to our center in the previous 6months for 3DHRAM to explore fecal incontinence or constipation, and who previously achieved CD, were eligible. 3DHRAM results were obtained for all classical parameters and the presence of a narrow band of high pressure in the anal canal during attempted defecation, which was recently found to be associated with RI in some studies. The sensitivity, specificity, and positive and negative predictive values were calculated for various 3DHRAM criterion in order to propose a diagnostic strategy for RI. Twenty-six patients (66%) presented with RI on CD. On 3DHRAM, according to our diagnostic strategy, the most relevant manometric criterion for the diagnosis of RI was the association of an anterior additional high-pressure area and an excessive perineal descent, with a positive predictive value of 100% [81.5-100], a specificity of 100% [75.3-100] and a sensibility of 69.2% [48.2-85.7]. In this study, 3DHRAM was used to diagnose RI, and we confirmed its use in the diagnosis of pelvic floor disorders. Further studies will be necessary to define classifications for these new anatomic data from 3DHRAM.

Assessment of pelvic floor morphology in women with chronic proctalgia by dnamic transperineal ultrasound

Objective To investigate the value of dynamic transperineal ultrasound in women with chronic proctalgia. Methods A prospective study was described.Women met the diagnostic criteria of chronic proctalgia were included. Patients were submitted to dynamic transperineal ultrasound. Bladder neck descent(BND), retrovesical angle(RVA), anorectal angle, rectocele and other indicators were observed at rest and during maximal Valsalva. Results A total of 33 patients with chronic proctalgia were included.BND was 1.1 -27.5 (13.21±7.77)mm, 4 of which were more than 25 mm. The RVA were greater than 140 ° in 8 patients during Valsalva maneuver. Six cases were diagnosed with cystourethrocele and 5 cases were diagnosed with isolated cystocele.Anorectal angles were 82.6-134.0 (113.12±10.95) ° at rest and 77.6-123.0 (110.10±13.28) ° during Valsalva respectively, there was no statistical significance (P>0.05). Fourteen cases were found rectocele with the depth 1.2-1.7 (1.38±0.17)cm; 14 cases were found rectal intussusceptions, 7 of which were associated with rectocele, 2 of which were associated with rectocele and enterocele. Conclusions Dynamic transperineal ultrasound can show the whole pelvic floor anatomy in female patients with chronic proctalgia to evaluate the pelvic floor function and detect other functional disorders. Key words: Ultrasonography; Chronic Proctalgia; Female; Pelvic floor