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Radiological findings in solitary rectal ulcer syndrome (SRUS) are well described for evacuation proctography (EP) but sparse for magnetic resonance defecography (MRD). In order to rectify this, we describe the spectrum of MRD findings in patients with histologically proven SRUS. MRD from twenty-eight patients (18 female; 10 males) with histologically confirmed SRUS were identified. MRD employed a 1.5-T magnet and a standardized technique with the rectal lumen filled with gel and imaged sagittally in the supine position, before, during, and after attempted rectal evacuation. A single radiologist observer with 5 years’ experience in pelvic floor imaging made the anatomical and functional measurements. Sixteen patients (10 female) demonstrated internal rectal intussusception and 3 patients (11%) demonstrated complete external rectal prolapse. Anterior rectoceles were noted in 12 female patients (43%). Associated anterior and middle compartment weakness (evidenced by excessive descent) was observed in 18 patients (64%). Cystocele was found in 14 patients (50%) and uterine prolapse was noted in 7 patients (25%). Enterocoeles were detected in 5 patients (18%) and peritoneocoele in 5 patients (18%). None had sigmoidocoele. Sixteen patients (57%) demonstrated delayed voiding and 13 patients (46%) incomplete voiding, suggesting defecatory dyssynergia. MRD can identify and grade both rectal intussusception and dyssynergia in SRUS, and also depict associated anterior and/or middle compartment descent. Distinction between structural and functional findings has important therapeutic implications.

Obstructed defecation syndrome may respond well to conservative treatment, yet some patients may need surgical intervention. The present report demonstrates the surgical treatment of a woman with obstructed defecation syndrome caused by anterior rectocele and internal rectal prolapse and associated with dolichocolon. A 39-year-old woman with a 5-year history of obstructed defecation syndrome caused by internal rectal prolapse and rectocele was investigated with anal manometry and defecography which confirmed the clinical diagnosis. The procedure entailed laparoscopic ventral mesh rectopexy to correct both internal rectal prolapse and anterior rectocele. In addition, since preoperative barium enema revealed the presence of a long redundant dolichocolon, resection of the sigmoid colon and creation of a stapled anastomosis were also performed. The patients’ symptoms were assessed using Wexner constipation score before and after surgery. The operation time of the procedure was approximately 90 min. No intraoperative adverse events were recorded. On follow-up, no complications as anastomotic leak, mesh-related morbidities, or ileus were recorded. At 6 months of follow-up, the patient reported significant improvement in symptoms with a decrease in the Wexner constipation score from 17 preoperatively to 6 postoperatively. No affection of the sexual function or de novo dyspareunia was reported by the patient. Combining resection of sigmoid colon with laparoscopic ventral mesh rectopexy seems to be a feasible option for patients with obstructed defection caused by internal rectal prolapse and anterior rectocele with coexisting dolichocolon. Larger studies with longer follow-up are needed to ascertain this preliminary finding.

Pelvic floor dysfunction is prevalent, with multifactorial causes and variable clinical presentations. Accurate diagnosis and assessment of the involved structures commonly requires a multidisciplinary approach. Imaging is often complementary to clinical assessment, and the most commonly used modalities for pelvic floor imaging include fluoroscopic defecography, magnetic resonance defecography, and pelvic floor ultrasound. This collaboration opinion paper was developed by representatives from multiple specialties involved in care of patients with pelvic floor dysfunction (radiologists, urogynecologists, urologists, and colorectal surgeons). Here, we discuss the utility of imaging techniques in various clinical scenarios, highlighting the perspectives of referring physicians. The final draft was endorsed by the Society of Abdominal Radiology (SAR), American Urogynecologic Society (AUGS), and the American Urological Association (AUA).

The sampling reflex is necessary to begin defecation or flatulence. It consists of a simultaneous rectoanal inhibitory reflex (RAIR) mediated by relaxation of the internal anal sphincter and rectoanal excitatory reflex (RAER) mediated by contraction of the external anal sphincter. The aim of this study was to evaluate the sampling reflex in patients with functional defecation disorder (FDD). A prospective cohort study was conducted on 58 obstructed defecation syndrome (ODS) patients with FDD. All 58 patients and 20 controls were evaluated with anorectal manometry to study the sampling reflex. Quantitative RAIR (total duration of reflex; maximal amplitude of relaxation; residual pressure at the lowest point of the RAIR) and RAER data (maximal amplitude of contraction; duration) were obtained. The straining test on manometry was considered positive for FDD if there was a muscle contraction/lack of relaxation or an insufficient pressure gradient for the passage of feces. Defecography was performed on all the patients with assessment of the anorectal angle and persistence or increase of puborectalis indentation. Fifty (86.2%) FDD patients had an altered sampling reflex, showing incomplete/short duration of RAIR and excessive contraction/duration of RAER. More specifically, there was a correlation between a positive straining test and a short total duration of RAIR (ρ 0.92) as well as with excessive duration of RAER (ρ 0.89). There was also a correlation between lack of muscle relaxation on defecography and short total duration of RAIR ((ρ 0.79) and between lack of muscle relaxation on defecography and excessive duration of RAER (ρ 0.83). Altered maximal amplitude relaxation had the highest sensitivity in detecting impairment of RAIR (87.9) while maximal amplitude contraction had the highest sensitivity in detecting impairment of RAER (89.6). High residual pressure at the lowest point of RAIR had the highest specificity in detecting impairment of RAIR (80.0) while RAER duration had the highest specificity in detecting impairment of RAER (77.7). The sampling reflex is impaired in patients with FDD. This finding provides an important insight into the pathogenesis of obstructed functional defecation.

Pelvic floor disorders are common and can negatively impact quality of life. Imaging of patients with pelvic floor disorders has been extremely heterogeneous between institutions due in part to variations in clinical expectations, technical considerations, and radiologist experience. In order to assess variations in utilization and technique of pelvic floor imaging across practices, the society of abdominal radiology (SAR) disease-focused panel on pelvic floor dysfunction developed and administered an online survey to radiologists including the SAR membership. Results of the survey were compared with published recommendations for pelvic floor imaging to identify areas in need of further standardization. MRI was the most commonly reported imaging technique for pelvic floor imaging followed by fluoroscopic defecography. Ultrasound was only used by a small minority of responding radiologists. The survey responses demonstrated variability in imaging utilization, patient referral patterns, imaging protocols, patient education, and interpretation and reporting of pelvic floor imaging examinations. This survey highlighted inconsistencies in technique between institutions as well as potential gaps in knowledge that should be addressed to standardize evaluation of patients with pelvic floor dysfunction.

X-ray defecography or magnetic resonance defecography (MRD) and high-resolution anorectal manometry (HR-ARM) are essential for the diagnosis of pelvic floor disorders (PFD). However, there is only scarce information available about the accuracy of MRD in the functional assessment of the pelvic floor. The aim of this study was to examine the accuracy of MRD in the diagnosis of pelvic floor disorders by examining the intra-test agreement with x-ray defecography and HR-ARM in patients with PFD. The study population included adults referred to our institution in January 2018–February 2020 for MRD as part of their evaluation of PFD. The MRD results were compared with X-ray defecography and HR-ARM. Forty-two patients were included in the study (36 female, 86%, mean age 56.9 years ± 15.8, range 19–86 years). When compared to X-ray defecography, the sensitivity of MRD for the evaluation of normal rest and squeeze pressures was high (0.83 and 1, respectively). High sensitivity rates were observed for the detection of pelvic organ prolapse and pelvic floor dyssynergia (0.84–1). When compared to HR-ARM, the sensitivity of MRD for the evaluation of squeeze and dyssynergia was very good (0.92and 1, respectively), and good for the evaluation of rest pressure (0.6). Inter-test agreement was high (0.5, 0.6, 0.6 for rest, squeeze and dyssynergia). Excellent rates of sensitivity as well as almost perfect intra-test agreement was found between abnormal balloon expulsion test and the diagnosis of dyssynergia and pelvic organ prolapse on MRD (1, 0.81). This study demonstrated substantial diagnostic agreement between HR-ARM and MRD in the diagnosis of pathological etiologies for functional pelvic floor disorders, mainly obstructed defecation syndrome.

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

Pelvic organ prolapse (POP) is assessed differently by gynecologists and radiologists. It is clinically staged by physical examination using the POP-Q (Pelvic Organ Prolapse Quantification) system and radiologically staged by modalities such as by Magnetic Resonance Defecography (MRD). The purpose of this study was to correlate the two methods of staging pelvic organ prolapse for each pelvic compartment by comparing correlative anatomic points and differences in technique. This understanding will help synthesize information from two different perspectives and bridge the gap between multiple specialists who participate in the care of patients with complex pelvic floor disorders. A retrospective single institution study comparison of patients who underwent both dynamic magnetic resonance pelvic floor imaging and pelvic organ prolapse quantification (POP-Q) at our medical center was done. Two urogynecologists performed the POP-Q and one fellowship-trained radiologist interpreted the MRD and both staged pelvic organ prolapse independently. A total of 280 patients underwent magnetic resonance imaging (MRI) of the pelvic floor from 1/2013 to 12/2017, of whom 68 met our inclusion criteria. When compared to POP-Q, MRI has strong, moderate, and weak correlation for quantification of anterior, middle, and posterior compartment prolapse, respectively. POP-Q measurements Aa, Ba, C, and D are analogous to true pelvic anatomical landmarks which are directly and consistently measurable by MRI, hence accounting for the better correlation in anterior and middle compartments when compared to measurements Ap and Bp which do not correlate with true anatomical landmarks, and hence can explain the weak correlation for posterior compartment prolapse. When comparing POP-Q to MRI, anterior and middle compartment prolapse have better correlation than posterior compartment prolapse. Inherent differences that exist in technique and anatomic landmarks used for staging pelvic organ prolapse by clinical exam and imaging criteria account for this. MRD, however, still provides anatomic details on static images, real time simultaneous overview of multi-compartmental prolapse, characterizes contents of cul-de-sac hernias and rectal evacuation on dynamic imaging. Corroborative information derived from both methods of staging organ will result in optimum patient care.

We describe Per Anal Endoscopic Rectopexy (PAER), a new treatment for complete rectal prolapse, which involves fixing the anterior rectal wall to the under-surface of the anterior abdominal wall and posterior rectal wall to the sacrum, through a submucosal tunnel (both endoluminally). This is a prospective single-centre pilot study done at a tertiary care centre. A total of 12 patients with a mean age of 48 years underwent the procedure. Constipation and incontinence were present in 8 and 4 patients, respectively and a significant improvement was seen in both following the procedure. A significant decrease in anorectal angle and its descent was also observed on post procedure magnetic resonance defecography. One patient had partial recurrence of prolapse. No major morbidity was observed. PAER is a minimally invasive and safe option for rectal prolapse, which needs to be validated in more patients over a longer follow up period.

Pelvic floor hernias from the posterior cul-de-sac most often contain small bowel and are called enteroceles, however may contain sigmoid colon (sigmoidocele) or only peritoneal fat (peritoneocele). These cul-de-sac hernias typically cause bulging of the posterior vaginal wall, while anterior vaginal wall bulges are typically secondary to bladder prolapse in patients with pelvic floor deficiency. We report a series of seven patients who presented with anterior vaginal wall “mass” or bulge after cystectomy and were found on magnetic resonance defecography (MRD) to have enteroceles or sigmoidoceles in the anterior rather than posterior compartment. MRD was instrumental for diagnoses in these patients and to exclude local recurrence of bladder malignancy. We also report five additional patients that were found to have bowel herniation anterior to the vaginal apex, but without history of cystectomy.

Pelvic floor dysfunction is a relatively common but often complex condition, presenting with a variety of clinical symptoms, especially when it involves multiple compartments. Clinical exam alone is often inadequate and requires a complementary imaging study. Magnetic resonance defecography (MRD) is an excellent noninvasive diagnostic study with its multiplanar capability, lack of ionizing radiation and excellent soft tissue resolution. It can identify both anatomic and functional abnormalities in the pelvic floor and specifically excels in its ability to simultaneously detect multicompartmental pathology and help with vital pre-operative assessment. This manuscript reviews the relevant anatomical landmarks, describes the optimal technique, highlights an approach to the interpretation of MRD, and provides an overview of the various pelvic floor disorders in the different anatomical compartments.

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

Recurrent prolapse of the posterior pelvic organ compartment presents a management challenge, with the best surgical procedure remaining unclear. We present functional outcome and patient satisfaction after laparoscopic and robotic ventral mesh rectopexy (VMR) with biological mesh in patients with recurrence. We analyzed data from 30 patients with recurrent posterior pelvic organ prolapse who underwent VMR with biological mesh from August 2012 to January 2018. Data included patient demographics and intra- and postoperative findings; functional outcome as assessed by Cleveland Clinic Constipation Score (CCCS), Obstructed Defecation Score Longo (ODS), and Cleveland Clinic Incontinence Score (CCIS); and patient satisfaction. CCCS, CCIS, and ODS were significantly improved at 6–12 months postoperatively and at last follow-up. Patient satisfaction (visual analog scale [VAS] 6.7 [0 to 10]), subjective symptoms (+ 3.4 [scale − 5 to + 5]), and quality of life improvement (+ 3.0 [scale from − 5 to + 5]) were high at last follow-up. The rates of morbidity and major complications were 13% and 3%, respectively. There were no mesh-related complications or deaths. Difference in type of previous surgery (abdominal or transanal/perineal) had no significant effect on results. VMR with biological mesh is a safe and effective option for patients with recurrent posterior pelvic organ prolapse. It reduces functional symptoms, has a low complication rate, and promotes patient satisfaction.

To compare prevalence and severity of multi-compartment pelvic floor dysfunction between supine magnetic resonance defecography with defecation (MRD) and supine dynamic MRI during Valsalva, both with and without rectal distention. This was an IRB-approved, HIPAA-compliant retrospective review of consecutive patients referred for MR Defecography. MRD protocol included imaging at rest, during pre-defecation Valsalva (Pre-DV), defecation (Def), and post-defecation Valsalva (Post-DV). The Post-DV images were performed after complete evacuation either during the defecation acquisition or, in cases where patient was unable to defecate during the examination, in a conventional toilet. Size of cystocele, vaginal prolapse, anorectal (AR) descent, and enterocele were measured on all acquisitions relative to the pubococcygeal line. Rectocele size was recorded in anteroposterior dimension. The presence or absence of rectal intussusception (RI) was documented. The prevalence, absolute size, and grades of prolapse, rectocele, and RI were compared between the acquisitions using pair-wise ANOVA, Friedman, Dunn pair-wise, and Cochran–Mantel–Haenszel tests. 30 patients were included in the final analysis. Higher prevalence of cystocele, vaginal prolapse, enterocele, AR descent grade 2 or higher, rectocele grade 2 or higher, and RI were seen on Def compared to Post-DV and Pre-DV. Cystocele, vaginal prolapse, enterocele, AR descent, and rectocele sizes were significantly larger on Def compared to Post-DV by 0.7−1.95 cm (p ≤ 0.007). Prolapse in all compartments and rectocele size were significantly larger on Def compared to Pre-DV (p

To develop recommendations for magnetic resonance (MR) defecography technique based on consensus of expert radiologists on the disease-focused panel of the Society of Abdominal Radiology (SAR). An extensive questionnaire was sent to a group of 20 experts from the disease-focused panel of the SAR. The questionnaire encompassed details of technique and MRI protocol used for evaluating pelvic floor disorders. 75% agreement on questionnaire responses was defined as consensus. The expert panel reached consensus for 70% of the items and provided the basis of these recommendations for MR defecography technique. There was unanimous agreement that patients should receive coaching and explanation of commands used during MR defecography, the rectum should be distended with contrast agent, and that sagittal T2-weighted images should include the entire pelvis within the field of view. The panel also agreed unanimously that IV contrast should not be used for MR defecography. Additional areas of consensus ranged in agreement from 75 to 92%. We provide a set of consensus recommendations for MR defecography technique based on a survey of expert radiologists in the SAR pelvic floor dysfunction disease-focused panel. These recommendations can be used to develop a standardized imaging protocol.

Whether used as the primary diagnostic test or reserved as a problem-solving examination, fluoroscopic defecography (FD) remains an important tool in the workup and treatment of defecatory disorders. FD is a well-established, simple, and rapid examination that most closely resembles the actual process and position that a patient uses to enable defecation and provides both qualitative and quantitative information on the defecatory process. FD is indicated when re-creating the act of defecation is necessary, especially in patients with symptoms of obstructed defecation and where symptoms do not correlate with prior examinations such as MRI. Also, FD may help the patient understand the severity of their condition, better informing them of the structural and functional pathology, and aid in discussions with the surgeon regarding plans for treating their complex pelvic floor and defecatory problems. This review provides an up-to-date, comprehensive summary of FD and describes the indications for, techniques of, and common pathology encountered.

Although the main function of the suspensory ligaments of the vaginal apex is to prevent its descent toward the vaginal introitus, there remains limited information regarding its normal physiological motion. This study was aimed at quantifying the motion of the non-prolapsed vaginal apex during strain and defecation maneuvers. This study represents a sub-analysis of a parent study that was aimed at evaluating rectal mobility with regard to obstructed defecation symptoms. Patients with normal apical vaginal support who had undergone MR defecography were entered into the study. For each patient, midsagittal images at rest, maximum strain, and maximum evacuation were utilized. The location of the cervicovaginal junction, S4–S5 intervertebral disc, sacral promontory, and hymen were identified. Vectors were calculated from each of these landmarks to the vaginal apex to compare vector angles and magnitudes across subjects. Twelve patients were included in this study. At rest, the vagina extends from the hymen, which is inferior and posterior to the inferior symphysis pubis, to the vaginal apex at an angle of 45.2° ± 14.5° relative to the pubococcygeal line. This angle became more acute with strain and even more so during maximum evacuation (14.1° ± 9.0°, p

To evaluate the reason for failure of STARR (stapled transanal rectal resection) operation for obstructed defecation. A retrospective study (June 2012–December 2017) was performed using a prospectively maintained database of patients who underwent STARR operation for ODS (obstructed defecation syndrome), complaining of persisting or de novo occurrence of pelvic floor dysfunctions. Postoperative St Mark’s and ODS scores were evaluated. A VAS was used to score pelvic pain. Patients’ satisfaction was estimated administering the CPGAS (clinical patient grading assessment scale) questionnaire. Objective evaluation was performed by dynamic proctography and anorectal manometry. Ninety patients (83.3% females) operated for ODS using STARR technique were evaluated. Median ODS score was 19 while 20 patients (22%) reported de novo fecal urgency and 4 patients a worsening of their preoperative fecal incontinence. Dynamic proctography performed in 54/90 patients showed a significant (> 3.0 cm) rectocele in 19 patients, recto-rectal intussusception in 10 patients incomplete emptying in 24 patients. When compared with internal normal standards, anorectal manometry showed decreased rectal compliance and maximum tolerable volume in patients with urgency. Nine patients reported a persistent postoperative pelvic pain (median VAS score 6). Failure of STARR to treat ODS, documented by persisting ODS symptoms, fecal urgency, or chronic pelvic pain, is often justified by the persistence or de novo onset of alteration of the anorectal anatomy at defecation. This occurs in about half of the patients, but in 40% of the cases who complained of incomplete emptying or incontinence, anatomical abnormalities were not recognized.

This study aims to investigate functional results and recurrence rate after stapled transanal rectal resection (STARR) for rectocele associated with obstructive defection syndrome (ODS). A study was conducted on patients with ODS symptoms associated with symptomatic rectocele ≥ 3 cm on dynamic defecography who had STARR at our institution between 01/2007 and 12/2015. Data were prospectively collected and analyzed. ODS was evaluated using the Wexner constipation score. Primary outcomes were functional results, determined by the improvement in 6-month postoperative Wexner constipation score, and 1-year recurrence. Secondary outcomes were operative time, time to return to work, pain intensity measured using the visual analogue scale (VAS), patient satisfaction, and overall postoperative morbidity and mortality at 30 days. Two-hundred-sixty-two consecutive female patients [median age 54 years (range 20–78)] were enrolled in the study. The median duration of follow-up was 79 months (range 30–138). Sixty (23%) patients experienced postoperative complications, but only 9 patients required reinterventions for surgical hemostasis (n = 7), fecal diversion for anastomotic leakage (n = 1), and recto-vaginal fistula repair (n = 1). Only 1 intraoperative complication (stapler misfire) was reported, and there were no deaths. There was a statistically significant (p

Restorative surgery for rectal cancer is usually criticized by its functional outcomes. The aim of this study is to assess the efficacy “taeniectomy” pouch in comparison with transverse coloplasty pouch. This was a prospective controlled study. Most patients who were candidate for low rectal resection presented to colorectal unit at Cairo university hospitals during the period from February 2013 to August 2016 were divided into two groups. The total number of patients enrolled in the study was 180 patients. Ninety patients were subjected to low rectal resection with the transverse coloplasty pouch, and 90 patients were subjected to low rectal resection with the newly described taeniectomy pouch. Safety and feasibility of both techniques were assessed about leakage, operative time, difficulty in evacuation, incontinence, number of daily motions and postoperative urgency. Both groups were assessed clinically, by means of defecography and anorectal manometry. There was no significant statistical difference between taeniectomy and transverse coloplasty regarding postoperative leakage (P value = 0.988), postoperative mortality (P value = 0.99) and functional outcomes including number of motions per day (P value was 0.403 at 3 months and 0.361 at 12 months), urgency (P value was 0.688), continence grade (P value was 0.320 and 0.683 in 3 and 12 months, respectively) and manometric findings. However, taeniectomy is statistically significant better in terms of operative time (P value = 0.001). Taeniectomy is a newly described, technically easier technique for pouch formation after low rectal resection that can be used as a safe and effective alternative for the widely used transverse coloplasty.

Background Clinically diagnosing high-grade (III–V) rectal prolapse might be difficult, and the prolapse can often be overlooked. Even though defecography is the significant diagnostic tool for rectal prolapse, it is noticed that rectoanal inhibitory reflex (RAIR) can be associated with rectal prolapse. This study investigated whether RAIR can be used as a diagnostic factor for rectal prolapse. Methods In this retrospective study, we evaluated 107 patients who underwent both anorectal manometry and defecography between July 2012 and December 2019. Rectal prolapse was classified in accordance with the Oxford Rectal Prolapse Grading System. Patients in the high-grade (III–V) rectal prolapse (high-grade group, n = 30), and patients with no rectal prolapse or low-grade (I, II) rectal prolapse (low-grade group, n = 77) were analyzed. Clinical variables, including symptoms such as fecal incontinence, feeling of prolapse, and history were collected. Symptoms were assessed using yes/no surveys answered by the patients. The manometric results were also evaluated. Results Frequencies of fecal incontinence (p = 0.002) and feeling of prolapse (p p = 0.011) and squeezing (128.7 vs. 165 mmHg, p = 0.010) anal pressures were significantly lower in the high-grade group. The frequency of absent or impaired RAIR was significantly higher in the high-grade group (19 cases, 63% vs. 20 cases, 26%, p p p = 0.001) were independent factors of high-grade (III–V) rectal prolapse. In addition, the percentage of the absent or impaired RAIR significantly increased with grading increase of rectal prolapse (p Conclusions Absent or impaired RAIR was a meaningful diagnostic factor of high-grade (III–V) rectal prolapse. Furthermore, the absent or impaired reflex had a positive linear trend according to the increase of rectal prolapse grading.

Background Pelvic floor dysfunction affects the lifestyle of women worldwide; the aim of this study is to evaluate the role of static MRI and dynamic MR defecography in the diagnosis of the posterior compartment of pelvic floor dysfunction. This prospective study included 50 female patients. All of them presented with pelvic floor dysfunction. Static and dynamic MRI were performed for all patients after injection of 120–150 ml of intrarectal gel and voiding 2 h before examination. Dynamic MRI was performed at rest, squeezing, straining phases, and during defecation. Results MR defecography can detect posterior compartment pathology with high sensitivity and specificity. We found anterior rectocele in 26 patients (52%). Rectocele incidence was analyzed and compared to postoperative reports, and the receiver operator curve (ROC) was calculated that showed area under the curve (AUC) of 0.998. The cut-off value of 1.95 cm gives a sensitivity of 96.4% and specificity of 100% during straining. The percentage of anismus was 26%, rectorectal intussusception 52%, anal prolapse types (rectoanal intussusception 14% and external prolapse 8%), and peritoneocele 34%. Conclusion MRI is a valuable imaging modality that can be used to diagnose pelvic floor disorders and does not involve the risk of exposure to ionizing radiation. It can direct the surgical procedure and thus improve the post-operative results and decrease the rate of recurrence due to missed pathology.

Physiological changes after laparoscopic ventral rectopexy (LVR) in patients with rectoanal intussusception (RAI) remain unclear. This study was undertaken to evaluate physiological and morphological changes after LVR for RAI, and to study clinical outcomes following LVR with special reference to fecal incontinence (FI). The study was conducted on patients who had LVR for RAI between February 2012 and December 2016 at our institution Patients with RAI and FI were included in the study. Patients with RAI and obstructed defecation and those with RAI and neurologic FI were not included. The patients had anorectal manometry preoperatively, and 3, 6, and 12 months postoperatively. Defecography was performed before and 6 months after the procedure. FI was evaluated using the Fecal Incontinence Severity Index (FISI). There were 34 patients (median age 77 years (range 60–93) years). Thirty-two patients (94%) were female and the median number of vaginal deliveries was 2 (range 0–5). Neither maximum resting pressure nor maximum squeeze pressure increased postoperatively. There was an overall increase in both defecatory desire volume (median preoperative 75 ml vs. 90 ml at 12 months; p = 0.002) and maximum tolerated volume (median preoperative 145 ml vs.175 ml at 12 months; p = 0.002). Postoperatively, RAI was eliminated in all patients but one, although 13 had residual rectorectal intussusception found at defecography. There was an overall reduction in both rectocele size (median preop 29 mm vs. postop 10 mm; p = 0.008) and pelvic floor descent (median preop 26 mm vs. postop 20 mm; p = 0.005). Twelve months after surgery, a reduction of at least 50% was observed in the FISI score for 31 incontinent patients (91%). LVR for RAI produced adequate improvement of FI, and successful anatomical correction of RAI was confirmed by postoperative proctography. Postoperative increase in the rectal volume may have a positive effect on continence.

Variability in functional outcome after ileal pouch-anal anastomosis (IPAA) is to a large extent unexplained. The aim of this study was to use MRI to evaluate the morphology, emptying pattern and other pathology that may explain differences in functional outcome between well-functioning and poorly functioning pouch patients. A secondary aim was to establish a reference of normal MRI findings in pelvic pouch patients. From a previous study, the best and worst functioning patients undergoing IPAA surgery between 2000 and 2013 had been identified and examined with manovolumetric tests (N = 47). The patients were invited to do a pelvic MRI investigating pouch morphology and emptying patterns, followed by a pouch endoscopy. Forty-three patients underwent MRI examination. We found no significant morphological or dynamic differences between the well-functioning and poorly functioning pouch patients. There was no correlation between urge volume and the volume of the bony pelvis, and no correlation between emptying difficulties or leakage and dynamic MRI findings. Morphological MRI signs of inflammation were present in the majority of patients and were not correlated to histological signs of inflammation. Of the radiological signs of inflammation, only pouch wall thickness correlated to endoscopic pouchitis disease activity index scores. It seems MRI does not increase the understanding of factors contributing to functional outcome after ileal pouch-anal anastomosis. Unless there is a clinical suspicion of perianal/peripouch disease or pelvic sepsis, MRI does not add value as a diagnostic tool for pelvic pouch patients. Endoscopy remains the golden standard for diagnosing pouch inflammation.

Resection rectopexy is performed to correct the anatomic defect associated with rectal prolapse. The aim of the study was to determine whether the change in the radiological prolapse grade has an influence on patients’ symptoms and quality of life. The study investigated 40 patients who underwent resection rectopexy for rectal prolapse. The following were determined before and after surgery: radiological prolapse grade, anorectal angle and pelvic floor position in defecography, clinical symptoms (Cleveland Clinic Incontinence and Constipation Scores, Kelly-Hohlschneider Score), quality of life. Defecography revealed postoperative improvement in the prolapse grade and pelvic floor position (p

Magnetic resonance defecography (MRD) allows for dynamic visualisation of the pelvic floor compartments when assessing for pelvic floor dysfunction. Additional benefits over traditional techniques are largely unknown. The aim of this study was to compare detection and miss rates of pelvic floor abnormalities with MRD versus clinical examination and traditional fluoroscopic techniques.A systematic review and meta-analysis was conducted in accordance with recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were accessed. Studies were included if they reported detection rates of at least one outcome of interest with MRD versus EITHER clinical examination AND/OR fluoroscopic techniques within the same cohort of patients.Twenty-eight studies were included: 14 studies compared clinical examination to MRD, and 16 compared fluoroscopic techniques to MRD. Detection and miss rates with MRD were not significantly different from clinical examination findings for any outcome except enterocele, where MRD had a higher detection rate (37.16% with MRD vs 25.08%; OR 2.23, 95% CI 1.21-4.11, p = 0.010) and lower miss rates (1.20 vs 37.35%; OR 0.05, 95% CI 0.01-0.20, p = 0.0001) compared to clinical examination. However, compared to fluoroscopy, MRD had a lower detection rate for rectoceles (61.84 vs 73.68%; OR 0.48 95% CI 0.30-0.76, p = 0.002) rectoanal intussusception (37.91 vs 57.14%; OR 0.32, 95% CI 0.16-0.66, p = 0.002) and perineal descent (52.29 vs 74.51%; OR 0.36, 95% CI 0.17-0.74, p = 0.006). Miss rates of MRD were also higher compared to fluoroscopy for rectoceles (15.96 vs 0%; OR 15.74, 95% CI 5.34-46.40, p 0.00001), intussusception (36.11 vs 3.70%; OR 10.52, 95% CI 3.25-34.03, p = 0.0001) and perineal descent (32.11 vs 0.92%; OR 12.30, 95% CI 3.38-44.76, p = 0.0001).MRD has a role in the assessment of pelvic floor dysfunction. However, clinicians need to be mindful of the risk of underdiagnosis and consider the use of additional imaging.

As laparoscopic ventral rectopexy (LVR) gained increasing popularity in the past decade, studies from non-western area remain rare. The aim of this pilot study is to evaluate the efficacy and safety of LVR for obstructed defecation (OD) in Chinese patients with overt pelvic structural abnormalities.A series of 19 consecutive patients is presented undergoing LVR for OD. All patients showed various forms of pelvic structural abnormalities which were verified by dynamic defecography exam. Data was prospectively recorded and the functional outcomes were evaluated using the Cleveland Clinic Constipation Score (CCCS) and Patients Assessment of Constipation Quality of Life Score (PAC-QoL).Pelvic structural abnormalities of the 19 patients included external rectal prolapse (ER) in 10.5% (2/19), high grade internal rectal prolapse (IR) in 57.8% (11/19), rectocele in 52.6% (10/19), enterocele in 15.7% (3/19), cystocele/vaginal prolapse in 15.7 (3/19), descending perineum (DP) in 63.5% (12/19). 89.4% patients (17/19) showed at least two co-existed abnormalities and 15.7% (3/19) showed multicompartmental abnormalities. The mean follow-up was 9 months (range 1-18). No mesh-related complication was observed. At last available follow-up (LAFU), improvement of OD symptom was observed in 15 (78.9%) patients, the mean scores of CCCS decreased from 17 to 10 (p 0.05), all four subsets of PAC-QoL scores improved, and three of them (physical discomfort, worries and concerns, satisfaction) showed statistical significance (p 0.05).Laparoscopic ventral rectopexy appears to be a safe and effective procedure for obstructed defecation in Chinese patients with overt pelvic structural abnormalities in short-term follow-up.

Though biofeedback therapy is often effective in patients with fecal evacuation disorder (FED), a common cause of chronic constipation (CC) in tertiary practice, data on anorectal physiological parameters following it are scanty. Consecutive patients with FED with CC diagnosed by abnormalities in at least two of the three tests (anorectal manometry, defecography, and balloon expulsion test [BET]) undergoing biofeedback (two sessions per day, 30 min each, for 2 weeks) during a 3-year period were analyzed. Clinical evaluation, anorectal manometry (ARM), and BET were performed at the beginning and after biofeedback. Incomplete evacuation 42/43 (98%), straining 40/43 (93%), and feeling of outlet obstruction 35/43 (81%) were the most common symptoms among these 43 patients (median age 44 years, range 18–76, 30 [71%] male). All the three tests (defecography, BET, and ARM) were abnormal in 17 (40%) patients and the others had two abnormal tests. Improvement in physiological parameters was noted following biofeedback (median residual anal pressure during defecation 99 mmHg (range 52–148) vs. 78 mmHg (37–182), p = 0.03; maximum intra-rectal pressure 60 mmHg (90–110) vs. 76 mmHg (31–178); p = 0.01; defecation index 1.1 (0.1–23.0) vs. 3.2 (0.5–29.0); p = 0.001). Dyssynergia on ARM and BET got corrected in 22/34 (65%) and 18/30 (60%) patients. At a 1-month follow up, 23/37 (62%) patients reported satisfactory symptomatic improvement. Biofeedback not only improves symptoms but also anorectal physiological parameters in patients with FED.

Anterior rectocele is a common morphological condition in patients with obstructive defecation syndrome. Typical symptoms include incomplete evacuation, transanal or transvaginal digitation and soiling, which is frequently interpreted as fecal incontinence. Diagnosis of rectocele is made clinically and functional assessment of rectocele can be performed by dynamic imaging, e.g. by magnetic resonance (MR) defecography. Primary treatment should be conservative. Concerning surgical treatment, transanal, transperineal, transvaginal and transabdominal procedures are available. Evidence-based guidelines for surgical treatment are still lacking. The question whether rectocele is a cause or a consequence of obstructive defecation syndrome remains controversial. Accordingly, indications for surgical correction of rectocele should be considered with caution.

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 ± 16.2 years, 174 males), 135/242 (55.8 %), 57/249 (22.9 %), and 83/136 (61.0 %) had abnormal balloon expulsion test (>200 g), anorectal manometry [>100 mmHg resting pressure (n = 4), >167 mmHg squeeze pressure (n = 46), and both (n = 7)], and defecography (anorectal angle not opening by >15° during defecation, perineal descent ≥4 cm, 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 [≥30 min; 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.

Rectoanal intussusception (RAI) is a common finding on evacuation proctography in patients with defecation disorders. However, it remains unclear whether intussusception morphology affects the severity of fecal incontinence (FI). The aim of this study was to examine the effect of morphology during defecation on the severity of FI in patients with RAI. We included 80 patients with FI who were diagnosed as having RAI on evacuation proctography. Various morphological parameters were measured, and the level of RAI was divided by the extent of descent onto (level I) or into (level II) the anal sphincter. FI symptoms were documented using the FI Severity Index (FISI). Twenty-eight patients had level I and 52 had level II RAI. The mean (range) FISI score was 24.0 (8–47). FISI scores tended to be significantly higher in level II than in level I [26.3 (10–47) vs. 21.8 (8–42); p = 0.05]. The mean anterior intussusception descent was significantly greater in level II than in level I [24.2 (9.2–39.5) vs. 17.7 (7.8–39.4) mm; p

Background Following injection sclerotherapy using ALTA (aluminum potassium sulfate and tannic acid) (ALTAS) and transanal rectocele repair (TAR), changes in anorectal physiology were analyzed to compare the significance of the two treatments. Methods ALTAS was administered to 23 patients and 18 patients were treated using TAR. Efficacy measures included changes in defecography, anorectal manometry and constipation scoring system value. Results This was a retrospective cohort analysis conducted on prospectively collected data. Comparing anorectal physiology pre- and post- ALTAS, a statistically significant difference in push was observed with pre-ALTAS treatment (pre-A) at 104.33 ± 4.91° compared with post-ALTAS treatment (post-A) at 113.95 ± 4.74° (p

to prospectively compare two rectal filling techniques for dynamic MRI of pelvic floor disorders (PFD). Twenty-six patients with PFD underwent the two techniques during the same procedure, one based on rectal placement of a balloon-catheter filled with saline and air insufflation (air-balloon technique or AB); another based on rectal filling with 180 cc of gel (gel-filling technique or GF). The examinations were compared for assessment and staging of PFD, including rectal-descent, rectocele, cystocele, colpocele, enterocele, rectal invagination. Surgery and clinical examinations were the gold standard. AB showed sensitivity of 96 % for rectal descent, 100 % for both rectocele and colpocele, 86 % for rectal invagination and 100 % for enterocele; understaged 11 % of rectal descents and 19 % of rectoceles. GF showed sensitivity of 100 % for rectal descent, 91 % for rectocele, 83 % for colpocele, 100 % for rectal invagination and 73 % for enterocele; understaged 3.8 % of rectal descent and 11.5 % of rectoceles. Both techniques showed 100 % of specificity. Agreement between air-balloon and gel filling was 84 % for rectal descent, 69 % for rectocele, 88 % for rectal invagination, 84 % for enterocele, 88 % for cystocele and 92 % for colpocele. Both techniques allowed a satisfactory evaluation of PFD. The gel filling was superior for rectal invagination, the air-balloon for rectocele and anterior/middle compartment disorders. • A standardized MRI technique for assessing pelvic floor disorders is not yet established. • This study compares two MRI techniques based on different rectal filling: air-balloon versus gel. • Both MRI techniques proved to be valuable in assessing PFD, with good agreement. • Air-balloon technique is more hygienic and better tolerated than the gel-filling technique. • Gel was superior for rectal invagination, air-balloon for rectocele and uro-genital prolapses.

Dyssynergic defecation can be difficult to diagnose. Anorectal manometry and defecography are often used to make this diagnosis. However, these tests are expensive and require expertise. Balloon expulsion testing may be a simple alternative. We compared balloon expulsion to anorectal manometry and defecography for diagnosing dyssynergia in women with chronic constipation. We conducted a retrospective review. All women presenting for evaluation of chronic constipation who underwent concurrent balloon testing, manometry, and defecography were included. A diagnosis of dyssynergic defecation was established by either defecography revealing prolonged/incomplete rectal evacuation and/or by manometry revealing paradoxical contraction/inadequate relaxation of the pelvic floor. Inability to expel a 50-ml balloon defined dyssynergic defecation by balloon testing. Sensitivity, specificity, and predictive values were calculated. A total of 61 women met inclusion criteria. Mean age was 50 years. There were 36 women (59 %) who met Rome III criteria for dyssynergic defecation on defecography and/or manometry. Only 12 of these 36 (33 %) were similarly diagnosed by balloon testing. The sensitivity and positive predictive value of balloon testing for dyssynergia were 33 and 71 %, respectively. Of the 25 (41 %) women who did not meet Rome III criteria for dyssynergia on defecography and/or manometry, 20 (80 %) also had negative balloon testing. Thus, the specificity and negative predictive value of balloon testing for diagnosing dyssynergia were 80 and 50 %, respectively. In our population, balloon expulsion was not an ideal screening test for dyssynergic defecation in women with constipation. Multimodal testing is necessary for more accurate diagnosis.

X-ray defecography is considered the gold standard for imaging pelvic floor pathology. However, it is limited by the capability to demonstrate only the posterior pelvic compartment, significant radiation exposure, and inconvenience. Dynamic transperineal ultrasound (DTP-US) can visualize all of three pelvic floor compartments, is free of radiation, and does not cause significant discomfort. The aim of this study was to evaluate the level of consistency between defecography (DEF) and DTP-US in the diagnosis of pelvic floor deformations. One hundred and five women (age 56 ± 11 years) suffering from constipation and fecal incontinence were clinically evaluated and further examined by DEF and DTP-US. The rate of diagnosis of pelvic floor hernias using the DTP-US was compared to that found on DEF. The specificity for the diagnosis of rectoceles was of 82 % for mid-size rectocele and 98 % for large rectoceles, and the sensitivity was of 59 % for mid-size rectoceles and 50 % for larger rectoceles. The sensitivity for the detection of intussusceptions, enteroceles, and rectal prolapse were 82, 74, and 75 %, respectively. The specificity was 84 % for the detection of intussusception, 92 % for enteroceles, and 97 % for the diagnosis of rectal prolapse. Higher rates of DTP-US diagnosis were obtained when the intussuscepted rectum moved closer toward the ultrasound probe. The sensitivity of DTP-US was good to excellent and the specificity was high. The added value of this technique in exploring all the compartments of the pelvic floor as well as the perineal muscles makes DTP-US a preferred procedure.

The goal of this study is to review MRI defecography, interpretation, and reporting. The multifactorial etiology of pelvic floor dysfunction has led to a variety of treatments with varying degrees of success which are dependent on proper pretreatment diagnosis and characterization. The ability of MRI defecography to identify and characterize isolated or multiple coexistent abnormalities has led to its significantly increased utilization in the diagnosis and successful treatment of pelvic floor dysfunction. Female pelvic floor dysfunction constitutes a spectrum of pathologic conditions afflicting a large proportion of women throughout the world. Knowledge of important landmarks and measurements depicted during MRI defecography is paramount in detecting and determining the severity of these conditions which allows the referring physician to appropriately tailor specific treatment.

This retrospective observational study was designed to assess patients’ satisfaction after anterior rectopexy, with or without sacropexy, for treatment of symptomatic rectocele in a group of women with anterior rectoceles. Between February 1995 and March 2011, all female patients who underwent an anterior rectopexy for large (>grade 2) anterior rectocele were included in the study. Preoperatively, the rectocele was assessed at rectovaginal examination and a defecography was performed. Rectovaginal examination was repeated in all patients 6 weeks postoperatively and a control defecography was performed 6 months after surgery. Follow-up included a standard telephone questionnaire and chart review. The surgical techniques used were anterior rectopexy (ARP; n = 21) and ARP + sacropexy (ARP + SP; n = 20). Mean age of the study group was 60 years (range = 36–77) and median parity was 2.6 (range = 0–8). Median follow-up from anterior ARP ± SP to functional assessment was 40 months (range = 4–83). In both groups, two of the initial main clinical symptoms (discomfort due to feeling of prolapse and outlet obstruction) improved significantly (p grade 2) anterior rectocele.

Colonic transit time and defaecography are well known, commonly used studies for evaluating patients with chronic constipation. The aim of this study was to compare colonic transit time with radiopaque markers and defaecography in female patients with obstructed defaecation. In a prospective observational study, between January 2010 and December 2012, a total of 30 female patients, mean age 60 years, with symptoms of obstructed defaecation were subjected to colonic transit time and defaecography, and divided into two groups: normal or abnormal colon transit time. The results were statistically compared using the Chi-square test. The comparison of data between colonic transit time and defaecography showed the following groups: group 1 (6/30 = 20 %) with normal colonic transit time but abnormal defaecography, and group 2 (24/30 = 80 %) with abnormal colonic transit time; the latter was further divided into two subgroups: group 2a (4/24 = 17 %), patients with inertia coli; group 2b (20/24 = 83 %), patients with impaired defaecation demonstrated at defaecography. There was a significant statistical difference between the radiological findings in these groups. This study confirmed the value of both defaecography and colonic transit time in assessing clinically obstructed women. Obstructed defaecation might not always be associated with abnormal colonic transit time. Likewise, not all constipated patients had signs of obstructed defaecation. The differential diagnosis between colonic slow transit constipation and constipation due to pelvic floor disorders is essential for an adequate strategy of care.

Rectal prolapse can present in a variety of forms and is associated with a range of symptoms including pain, incomplete evacuation, bloody and/or mucous rectal discharge, and fecal incontinence or constipation. Complete external rectal prolapse is characterized by a circumferential, full-thickness protrusion of the rectum through the anus, which may be intermittent or may be incarcerated and poses a risk of strangulation. There are multiple surgical options to treat rectal prolapse, and thus care should be taken to understand each patient's symptoms, bowel habits, anatomy, and pre-operative expectations. Preoperative workup includes physical exam, colonoscopy, anoscopy, and, in some patients, anal manometry and defecography. With this information, a tailored surgical approach (abdominal versus perineal, minimally invasive versus open) and technique (posterior versus ventral rectopexy +/- sigmoidectomy, for example) can then be chosen. We propose an algorithm based on available outcomes data in the literature, an understanding of anorectal physiology, and expert opinion that can serve as a guide to determining the rectal prolapse operation that will achieve the best possible postoperative outcomes for individual patients.

Pelvic floor dysfunctions represent a common health problem affecting particularly post-menopausal women impacting significantly the quality of life. A large number of these patients suffer for many years without proper treatment often due to the lack of objective findings necessary to plan proper treatment. Because abnormalities of the different pelvic compartments are frequently associated, thorough diagnostic characterization of how many compartments are affected is paramount in order to plan the management approach that can include a multidisciplinary surgical approach. This pictorial essay will review the different imaging methods used for the characterization of these disorders, how to do them and its rationale providing a clinically understandable interpretation with clinical correlates and a correlation between fluoroscopic and MR defecography in order to illustrate the strengths and shortcomings of each. The need to use a standardized, reliable, and clinically understandable method of quantification has become more obvious in the last decades with the increasing rate of scientific and professional interchanges. A review of the grading systems used to convey the imaging findings also highlights the importance of using a standardized tool for comparing and communicating clinical findings understandable to referring physicians with proven inter-observer and intra-observer agreement of the examinations.

Postoperative anorectal malformation patients frequently have defecatory dysfunction. MRI may be useful in the management of these patients. To analyze static and dynamic MRI findings in patients with defecatory dysfunction after correction of anorectal malformation (ARM), and compare differences between patients with constipation and fecal incontinence. Pelvic MRI studies of 20 constipated and 32 incontinent postoperative ARM patients were analyzed retrospectively to determine the location and morphology of the neorectum, presence of peritoneal fat herniation, presence of scarring, development of the striated muscle complex (SMC) and any other abnormalities. The two groups were then compared using χ 2-test. Eighteen patients also underwent MRI defecography to evaluate pelvic floor function and abnormalities are reported. The children with incontinence were more likely to have abnormal location of the neorectum (P = 0.031), increased anorectal angle (ARA) (P = 0.031) and peritoneal fat herniation (P = 0.032), and less likely to have dilation of the neorectum (P = 0.027), than the children with constipation. There were no significant differences between the two groups in incidence of focal stenosis of the neorectum (P = 0.797), presence of extensive scarring (P = 0.591) and developmental agenesis of the SMC (P > 0.05). MRI defecography showed 6 anterior rectoceles, 6 cystoceles and 18 pelvic floor descents. MRI is a helpful imaging modality in postoperative ARM patients with defecatory dysfunction, and it shows distinct differences between the children with constipation and incontinence and provides individualized information to guide further treatment.

We conducted an observational study to assess the hypothesis that the pelvic muscles actively open the anorectal lumen during defecation. Three groups of female patients were evaluated with video imaging studies of defecation using a grid or bony reference points. Eight patients with idiopathic fecal incontinence had video myogram defecography; eight with obstructive defecation had magnetic resonance imaging (MRI) defecating proctograms; and four normal patients had video X-ray or MRI defecating proctogram studies. In all three groups, the anorectum was stretched bidirectionally by three directional muscle force vectors acting on the walls of the rectum, effectively doubling the diameter of the rectum during defecation. The anterior rectal wall was pulled forwards, and the posterior wall backwards and downwards opening the anorectal angle, associated with angulation of the anterior tip of the levator plate (LP). These observations are consistent with a staged relaxation of some parts of the pelvic floor during defecation, and contraction of others. First, the puborectalis muscle relaxes. Puborectalis muscle relaxation frees the posterior rectal wall so that it can be stretched and opened by contraction of the LP and conjoint longitudinal muscle of the anus. Second, contraction of the pubococcygeus muscle pulls forward the anterior rectal wall, further increasing the diameter of the rectum. Third, when the bolus has entered the rectum, the external anal sphincter relaxes, and the rectum contracts to expel the fecal bolus. Our results are consistent with the hypothesis that pelvic striated muscle actively opens the rectal lumen, thereby reducing internal anorectal resistance to expulsion of feces. Controlled studies of electromyographic activity would be useful to further test this hypothesis.

This study prospectively compared the diagnostic capabilities of magnetic resonance (MR) imaging with conventional defecography (CD) in outlet obstruction syndrome.Nineteen consecutive patients with clinical symptoms of outlet obstruction underwent pelvic MR examination. The MR imaging protocol included static T2-weighted fast spin-echo (FSE) images in the sagittal, axial and coronal planes; dynamic midsagittal T2-weighted single-shot (SS)-FSE and fast imaging employing steady-state acquisition (FIESTA) cine images during contraction, rest, straining and defecation. MR images (including and then excluding the evacuation phase) were compared with CD, which is considered the reference standard.Comparison between CD and MR with evacuation phase (MRWEP) showed no significant differences in sphincter hypotonia, dyssynergia, rectocele or rectal prolapse and significant differences in descending perineum. Comparison between CD and MR without evacuation phase (MRWOEP) showed no significant differences in sphincter hypotonia, dyssynergia or enterocele but significant differences in rectocele, rectal prolapse and descending perineum. Comparison between MRWEP and MRWOEP showed no significant differences in sphincter hypotonia, dyssynergia, enterocele or descending perineum but significant differences in rectocele, rectal prolapse, peritoneocele, cervical cystoptosis and hysteroptosis.MR imaging provides morphological and functional study of pelvic floor structures and may offer an imaging tool complementary to CD in multicompartment evaluation of the pelvis. An evacuation phase is mandatory.

"Functional" imaging of anorectal and pelvic floor dysfunction has assumed an important role in the diagnosis and management of these disorders. Although defecography has been widely practiced for decades to evaluate the dynamics of rectal emptying, debate concerning its clinical relevance, how it should be done and interpreted continues. Due to the recognition of the association of defecatory disorders with pelvic organ prolapse in women, the need to evaluate the pelvic floor as a unit has arisen. To meet this need, defecography has been extended to include not only evaluation of defecation disorders but also the rest of the pelvic floor by opacifying the small bowel, vagina, and the urinary bladder. The term "dynamic cystocolpoproctography" (DCP) has been appropriately applied to this examination. Rectal emptying performed with DCP provides the maximum stress to the pelvic floor resulting in complete levator ani relaxation. In addition to diagnosing defecatory disorders, this method of examination demonstrates maximum pelvic organ descent and provides organ-specific quantification of organ prolapse, information that is only inferred by means of physical examination. It has been found to be of clinical value in patients with defecation disorders and the diagnosis of associated prolapse in other compartments that are frequently unrecognized by history taking and the limitations of physical examination. Pelvic floor anatomy is complex and DCP does not show the anatomical details pelvic magnetic resonance imaging (MRI) provides. Technical advances allowing acquisition of dynamic rapid MRI sequences has been applied to pelvic floor imaging. Early reports have shown that pelvic MRI may be a useful tool in pre-operative planning of these disorders and may lead to a change in surgical therapy. Predictions of hypothetical increase cancer incidence and deaths in patients exposed to radiation, the emergence of pelvic floor MRI in addition to questions relating to the clinical significance of DCP findings have added to these controversies. This review analyses the pros and cons between DCP and dynamic pelvic floor MRI, addresses imaging and interpretive controversies, and their relevance to clinical management.