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Anal fistula (AF) is a common referral to colorectal surgeons. Management remains challenging and sometimes controversial. Magnetic resonance imaging (MRI) is commonly performed in initial workup for AF. However, reports often lack key information for guiding treatment strategies. It has been shown that with structured radiology reports, there is less missing information. We present a structured MRI template report including 8 key descriptors of anal fistulas, whose effectiveness and acceptability are being assessed in a cross-sectional study (NCT04541238).

The optimal surgical treatment for anatomical anal stenosis (AS) remains to be determined. The aim of this study was to determine the rates of complications and recurrence after anoplasty for anatomical AS and, wherever feasible, compare the outcomes for the various techniques.A PROSPERO-registered systematic review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Medline, PubMed, Embase, Cochrane Library of Systematic Review, Scopus and Web of Science were searched for articles published up to May 2021. Studies that assessed the outcomes of anoplasty in adult patients with anatomical AS were selected. The primary outcomes were complications and recurrence. The methodological quality of studies was appraised using the Joanna Briggs Institute critical appraisal tools.From the total of 2705 unique screened records, 151 were assessed for eligibility. Only 29 studies (two prospective) met the inclusion criteria, reporting data on 556 patients [mean age 53 (18-83) years, 46% female]. Previous history of surgery for haemorrhoidal disease accounted for three quarters of cases. A total of 14 types of anoplasty were found, with the Y-V flap being the most performed technique [27% of cases (n = 149)]. Complications frequently occurred, with a pooled prevalence of 10.2% (95% CI 3.9%-24.1%) after Y-V flap and 11.5% (5.3%-23.0%) after rhomboid/diamond flap. Patients undergoing house flap achieved better results in terms of clinical improvement, satisfaction and quality of life compared with Y-V flap and rhomboid/diamond flap. When considering only studies with at least 12 months of follow-up, the pooled prevalence of recurrence was 4.7% (2.2%-9.8%), with significantly higher rates observed in the prospective versus retrospective series [pooled prevalence 18.9% (11.5%-29.5%) vs. 3.6% (1.7-7.8%), respectively; p 0.001].Both complications and recurrence were significantly lower after house flap compared with rhomboid/diamond and Y-V flap. Better designed multicentre studies with longer follow-up are needed to confirm these findings.CRD42021239493.

Background Obstructed defaecation syndrome (ODS) is difficulty in evacuating stools, requiring straining efforts at defaecation, having the sensation of incomplete evacuation, or the need to manually assist defaecation. This is due to a physical blockage of the faecal stream during defaecation attempts, caused by rectocele, enterocele, intussusception, anismus or pelvic floor descent. Evacuation proctography (EP) is the most common imaging technique for diagnosis of posterior pelvic floor disorders. It has been regarded as the reference standard because of extensive experience, although it has been proven not to have perfect accuracy. Moreover, EP is invasive, embarrassing and uses ionising radiation. Alternative imaging techniques addressing these issues have been developed and assessed for their accuracy. Because of varying results, leading to a lack of consensus, a systematic review and meta-analysis of the literature are required. Objectives To determine the diagnostic test accuracy of EP, dynamic magnetic resonance imaging (MRI) and pelvic floor ultrasound for the detection of posterior pelvic floor disorders in women with ODS, using latent class analysis in the absence of a reference standard, and to assess whether MRI or ultrasound could replace EP. The secondary objective was to investigate differences in diagnostic test accuracy in relation to the use of rectal contrast, evacuation phase, patient position and cut-off values, which could influence test outcome. Search methods We ran an electronic search on 18 December 2019 in the Cochrane Library, MEDLINE, Embase, SCI, CINAHL and CPCI. Reference list, Google scholar. We also searched WHO ICTRP and clinicaltrials.gov for eligible articles. Two review authors conducted title and abstract screening and full-text assessment, resolving disagreements with a third review author. Selection criteria Diagnostic test accuracy and cohort studies were eligible for inclusion if they evaluated the test accuracy of EP, and MRI or pelvic floor ultrasound, or both, for the detection of posterior pelvic floor disorders in women with ODS. We excluded case-control studies. If studies partially met the inclusion criteria, we contacted the authors for additional information. Data collection and analysis Two review authors performed data extraction, including study characteristics, 'Risk-of-bias' assessment, sources of heterogeneity and test accuracy results. We excluded studies if test accuracy data could not be retrieved despite all efforts. We performed meta-analysis using Bayesian hierarchical latent class analysis. For the index test to qualify as a replacement test for EP, both sensitivity and specificity should be similar or higher than the historic reference standard (EP), and for a triage test either specificity or sensitivity should be similar or higher. We conducted heterogeneity analysis assessing the effect of different test conditions on test accuracy. We ran sensitivity analyses by excluding studies with high risk of bias, with concerns about applicability, or those published before 2010. We assessed the overall quality of evidence (QoE) according to GRADE. Main results Thirty-nine studies covering 2483 participants were included into the meta-analyses. We produced pooled estimates of sensitivity and specificity for all index tests for each target condition. Findings of the sensitivity analyses were consistent with the main analysis. Sensitivity of EP for diagnosis of rectocele was 98% (credible interval (CrI)94%-99%), enterocele 91%(CrI 83%-97%), intussusception 89%(CrI 79%-96%) and pelvic floor descent 98%(CrI 93%-100%); specificity for enterocele was 96%(CrI 93%-99%), intussusception 92%(CrI 86%-97%) and anismus 97%(CrI 94%-99%), all with high QoE. Moderate to low QoE showed a sensitivity for anismus of 80%(CrI 63%-94%), and specificity for rectocele of 78%(CrI 63%-90%) and pelvic floor descent 83%(CrI 59%-96%). Specificity of MRI for diagnosis of rectocele was 90% (CrI 79%-97%), enterocele 99% (CrI 96%-100%) and intussusception 97% (CrI 88%-100%), meeting the criteria for a triage test with high QoE. MRI did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of MRI performed with evacuation phase was higher than without for rectocele (94%, CrI 87%-98%) versus 65%, CrI 52% to 89%, and enterocele (87%, CrI 74%-95% versus 62%, CrI 51%-88%), and sensitivity of MRI without evacuation phase was significantly lower than EP. Specificity of transperineal ultrasound (TPUS) for diagnosis of rectocele was 89% (CrI 81%-96%), enterocele 98% (CrI 95%-100%) and intussusception 96% (CrI 91%-99%); sensitivity for anismus was 92% (CrI 72%-98%), meeting the criteria for a triage test with high QoE. TPUS did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of TPUS performed with rectal contrast was not significantly higher than without for rectocele(92%, CrI 69%-99% versus 81%, CrI 58%-95%), enterocele (90%, CrI 71%-99% versus 67%, CrI 51%-90%) and intussusception (90%, CrI 69%-98% versus 61%, CrI 51%-86%), and was lower than EP. Specificity of endovaginal ultrasound (EVUS) for diagnosis of rectocele was 76% (CrI 54%-93%), enterocele 97% (CrI 80%-99%) and intussusception 93% (CrI 72%-99%); sensitivity for anismus was 84% (CrI 59%-96%), meeting the criteria for a triage test with very low to moderate QoE. EVUS did not meet the criteria to replace EP. Specificity of dynamic anal endosonography (DAE) for diagnosis of rectocele was 88% (CrI 62%-99%), enterocele 97% (CrI 75%-100%) and intussusception 93% (CrI 65%-99%), meeting the criteria for a triage test with very low to moderate QoE. DAE did not meet the criteria to replace EP. Echodefaecography (EDF) had a sensitivity of 89% (CrI 65%-98%) and specificity of 92% (CrI 72%-99%) for intussusception, meeting the criteria to replace EP but with very low QoE. Specificity of EDF for diagnosis of rectocele was 89% (CrI 60%-99%) and for enterocele 97% (CrI 87%-100%); sensitivity for anismus was 87% (CrI 72%-96%), meeting the criteria for a triage test with low to very low QoE. Authors' conclusions In a population of women with symptoms of ODS, none of the imaging techniques met the criteria to replace EP. MRI and TPUS met the criteria of a triage test, as a positive test confirms diagnosis of rectocele, enterocele and intussusception, and a negative test rules out diagnosis of anismus. An evacuation phase increased sensitivity of MRI. Rectal contrast did not increase sensitivity of TPUS. QoE of EVUS, DAE and EDF was too low to draw conclusions. More well-designed studies are required to define their role in the diagnostic pathway of ODS.

Background Mixed adeno-neuroendocrine carcinomas (MANEC) are a subgroup of mixed neuroendocrine non-neuroendocrine neoplasms (MiNEN) described as mixed neoplasms containing dual neuroendocrine and non-neuroendocrine components. The aim of this study was to appraise the prevalence of MANEC in the lower gastrointestinal (GI) tract and provide reliable estimates of survival. Method A systematic review was undertaken in accordance with PRISMA guidelines using PubMed, Embase, Cochrane Library of Systematic Review, Web of Science, and Scopus databases, and a Bayesian hierarchical survival pooled analysis was performed. Results Of 182 unique records identified, 71 studies reporting on 752 patients met the inclusion criteria. Mean age was 64.2 ± 13.6, with a male-to-female ratio of 1.25. Overall, 60.3% of MANEC were located in the appendix, 29.3% in the colon, and 10.4% in the anorectum. More than a quarter (29%) of patients had stage IV disease at diagnosis, with higher prevalence in appendiceal than colonic and anorectal primaries. More than 80% had a high-grade (G3) endocrine component. Of the 152 patients followed up for a median of 20 months (interquartile range limits, 16.5–32), median overall survival was 12.3 months (95% credible interval [95%CrI], 11.3–13.7), with a 1.12 [95%CrI, 0.67–1.83] age-adjusted hazard ratio between metastatic and non-metastatic MANEC. Stage IV disease at diagnosis was more prognostically unfavorable in cases of colonic compared to anorectal origin. Conclusion MANEC is a clinically aggressive pathological entity. The results of this study provide new insights for the understanding of tumor location within the lower GI tract and its prognosis in terms of overall survival.

High-resolution three-dimensional endoanal ultrasonography (3D-EAUS) clearly demonstrates the anatomy of the anal canal. All relevant structures, including the puborectalis muscle, the internal and external sphincter, the conjoined longitudinal layer, and the transverse perinei muscles, are visualized, and any sphincter disruptions or defects can be detected. The asymmetrical shape of the anal canal and the gender differences in the ventral part of the external sphincter are also easily evaluated in the different reconstructed planes of the three-dimensional volume. High-resolution three-dimensional endorectal ultrasound (3D-ERUS) provides an accurate visualization of the five-layer structure of the rectal wall and of all the pelvic organs adjacent to the rectum. The purpose of this chapter is to present the technique of 3D-EAUS and 3D-ERUS and to revise the ultrasonographic anatomy of the anorectal region.

Pelvic floor is still artificially divided into anterior, middle, and posterior compartments; however, abnormalities in one compartment frequently coexist with disorders in the other two compartments. Due to its complex anatomy and function, pelvic floor should be approached with a unitary vision by a multidisciplinary team of colorectal surgeons, urologists, urogynecologists, and radiologists. Imaging leads to a better understanding of the pathophysiology of pelvic floor disorders and helps clinicians to select the most adequate treatment and to understand the reasons of failures or recurrences. Integration and combination of different modalities (X-ray, ultrasound, and magnetic resonance imaging) provides comprehensive assessment of pelvic organ prolapse. Ultrasound may be performed with endovaginal, transperineal, and endoanal approaches. Technological innovations such as high-resolution 3D or 4D ultrasound, new software options, and data post-processing capabilities have further increased the accuracy of this procedure. However, the place of imaging in diagnostic algorithms of pelvic floor disorders is still controversial and often differs among specialties. The challenge for specialties dealing with patients with POP is that integrated imaging approach becomes part of the routine clinical practice.

Imaging techniques play a fundamental role in the diagnosis of pelvic floor disorders. Integrated and multicompartmental pelvic floor ultrasound (translabial, transperineal, endovaginal, endoanal, 3D/4D acquisitions, dynamic US) addresses all pelvic floor anatomy and functionality in one setting, allowing identification of coexisting dysfunctions of the three compartments. A variety of factors contributes to the overall quality of the ultrasound image. These include type of transducer, choice of imaging parameters, and the skilled use of the equipment by the operator. A good-quality image should contain information that is associated with high spatial resolution, high contrast resolution, and high temporal resolution.

Minor acute complications after anorectal surgery include pain, bleeding, infection, and urinary retention. Severe acute complications, i.e., pelvic sepsis, massive hemorrhage, although not common, can lead to significant patient morbidity and mortality. Long-term complications include chronic anorectal pain, anal stenosis or stricture, anorectal/rectovaginal fistulas, and fecal incontinence. Early and accurate diagnosis is crucial for the management of these conditions. This chapter will discuss the ultrasonographic assessment of complications after anorectal surgery.

The configuration of perianal sepsis and the relationship of abscesses or fistulae with internal and external sphincters are the most important factors influencing the results of surgical management. Preoperative identification of all loculate purulent areas, and definition of the anatomy of the primary fistulous tract, secondary extensions, and the internal opening play an important role in adequate planning of the operative approach, in order to ensure complete drainage of abscesses, prevent early recurrence after surgical treatment for anal fistulae, and to minimize iatrogenic damage of sphincters and the risk of minor or major degrees of incontinence. In this chapter, technical aspects and imaging interpretations of endoanal ultrasonography in the evaluation of perianal abscesses and fistulae will be presented. Accuracy and reliability of this modality and in comparison with transperineal ultrasound and magnetic resonance imaging are also discussed.

Endoanal ultrasonography (EAUS) is the “gold standard” investigation to differentiate between patients suffering with anal incontinence (AI) and intact sphincters and those with sphincter lesions (defects, scarring, thinning, thickening, and atrophy). High-resolution multiplanar reconstructions and rendering techniques further enhance the accuracy of EAUS. Ultrasonographic findings help the physician to select adequate treatment (medical therapy, rehabilitation, sphincteroplasty, graciloplasty, injection of bulking agents, and sacral nerve stimulation) and to monitor results following surgical treatment. In addition, detection of undiagnosed tears after vaginal delivery may be useful in counseling regarding the mode of subsequent delivery.

Chronic constipation is a syndrome characterized by symptoms of unsatisfactory defecation associated with infrequent stools and/or difficult stool passage. The pooled prevalence in the community is 14% worldwide and higher in women, with significant cost and healthcare utilization. Given a considerable symptom overlap within the three main subtypes of constipation (namely, normal transit, slow transit, and obstructive defecation), the predominant phenotype, and the pathophysiological mechanisms are nowadays recognized by performing specialist physiologic testing, mainly consisting of colonic transit study, anorectal manometry, electromyography, balloon expulsion test, X-ray, or magnetic resonance defecography. Over the last decade, ultrasound has been advocated as a noninvasive, cost-effective, and reliable tool to be added to the inventory of diagnostic modalities. Several approaches have been described, including transperineal (or translabial), endovaginal, and transanal. Consensus exists to complement the information provided by each modality to allow an integrated assessment of the pelvic floor.

Background: Pain is the most common complication after open excisional hemorrhoidectomy (OEH). We assessed the effectiveness of polycarbophil and Propionibacterium acnes lysate gel (Emorsan&reg, Gel) on pain control after OEH. Research design and methods: Fifty consecutive patients undergoing OEH were included. All patients received stool softeners and oral analgesia in the post-operative period. Emorsan&reg, Gel was also used topically by the last 25 patients (Emorsan&reg, Gel group (EG)) until Post-Operative Day 20 (POD 20). The primary outcome was the effectiveness of Emorsan&reg, Gel on pain relief using an 11-point visual analogue scale (VAS). Morbidity, wound healing (WH), and time to work were documented at POD 1, POD 10, POD 20, and POD 40. Results: Of the 50 patients enrolled, twenty-eight (56%) were males, median age, 49 (range, 28&ndash, 73) years. The VAS score decreased over time in all patients, with significantly lower scores at POD 20 in the EG (1.44 (SD, 1.16) vs. 2.12 (0.93) in the control group (CG), p = 0.045). All patients in the EG achieved complete WH at last follow-up, compared to only 17 (68%) in the CG (p = 0.004). The likelihood of WH was 66% higher in the EG (OR, 1.66 [95%CI, 0.80&ndash, 3.44, p = 0.172). Conclusions: Emorsan&reg, Gel is safe and effective at reducing pain after EOH, promoting earlier WH compared to standard care treatment.

Colon cancer is the third most common cancer in man and woman in the developed world. Laparoscopic right colectomy is the standard of care for right colon cancer. Since the first report on laparoscopic approach in 1991, the surgical technique has been improved and currently all procedure is performed intracorporeally. The ileo-colic anastomosis can be performed either intracorporeal and extracorporeal: the differences in clinical outcome, complications rate, hospital stay and quality of life between that two techniques are not still clear and a large number of studies has been published about that. According to most recent meta-analysis, intracorporeal anastomosis have showed better outcome in anastomotic leakage rate, surgical site infection rate, development of incisional hernia, postoperative pain and recovery of gastrointestinal function.

Objectives “Significant” obstetric anal sphincter injuries (OASIS) have been defined as visible defects of at least 30° in at least 4/6 slices using tomographic ultrasound imaging (TUI) with transperineal ultrasound (TPUS). The objective of this study was to assess if TUI is mandatory for the evaluation of OASIS. Methods Patients with a history of OASIS were evaluated by performing 3D-endoanal ultrasound (EAUS) and 3D-TPUS with and without TUI. Any damage to the internal (IAS) or external (EAS) anal sphincters was recorded and scored using the Starck’s and the Norderval’s systems. Intraobserver and inter-techniques correlations were calculated. Results From September 2012 to May 2015, 63 women, mean age 32.5 ± 4.6 years, with OASIS (3a: 26 pts., 41.3 %; 3b: 26 pts., 41.3 %; 3c: 6 pts., 9.5 %, 4: 4 pts., 6.3 %, “button hole” tear: 1 pt., 1.6 %). Inter-technique and intraobserver correlations were excellent (TUI: k = 0.9; sweeping technique: k = 0.85; EAUS: k = 0.9) in determining OASIS. Using the Starck’s Score, excellent correlation was found for both TPUS modalities (TUI: k = 0.86; sweeping technique: k = 0.89). However, for the different individual parameters, the correlation was moderate for EAS depth (TUI: k = 0.44; sweeping technique: k = 0.5) and good for IAS depth (TUI: k = 0.7; sweeping technique: k = 0.78). Similar results were found using the Norderval’s classification. Conclusions OASIS can be assessed by TPUS without TUI technique, dragging the rendered box and following the anal canal from the anal verge to the anorectal junction in the longitudinal plane and describing findings.

Proctology is one of the surgical specialties that suffered the most during COVID-19 pandemic. Using data from a cross-sectional worldwide web survey, we aimed to snapshot the current status of proctologic practice in Italy with differences between three macro areas (North, Centre, South). Specialists affiliated to renowned scientific societies with an interest in coloproctology were invited to join a 27-item survey. Predictive power of respondents’ and hospitals’ demographics on the change of status of surgical activities was calculated. The study was registered at ClinicalTrials.gov (NCT 04392245). Of 299 respondents from Italy, 94 (40%) practiced in the North, 60 (25%) in the Centrer and 82 (35%) in the South and Islands. The majority were men (79%), at consultant level (70%), with a mean age of 46.5 years, practicing in academic hospitals (39%), where a dedicated proctologist was readily available (68%). Southern respondents were more at risk of infection compared to those from the Center (OR, 3.30; 95%CI 1.46; 7.47, P = 0.004), as were males (OR, 2.64; 95%CI 1.09; 6.37, P = 0.031) and those who routinely tested patients prior to surgery (OR, 3.02; 95%CI 1.39; 6.53, P = 0.005). The likelihood of ongoing surgical practice was higher in the South (OR 1.36, 95%CI 0.75; 2.46, P = 0.304) and in centers that were not fully dedicated to COVID-19 care (OR 4.00, 95%CI 1.88; 8.50, P

OBJECTIVE To review our 6-year experience (2009-2015) in teaching three-dimensional pelvic floor ultrasonography workshops that utilized pelvic floor phantoms in the setting of an Objective Structured Assessment of Technical Skills methodology. METHODS Four-hour Objective Structured Assessment of Technical Skills workshops were given at several society meetings and involved a didactic session, a hands-on session using the pelvic floor phantoms, and a computer station session reviewing pelvic floor pathologies. We analyzed improvement in participants' diagnostic skills using a test with 60 illustrated questions of normal and pathologic findings in live human models. RESULTS Two hundred forty-three attendees completed the 60-question test before and after attending the workshop. Paired t test showed a significant improvement in attendees' average scores after the workshop in all categories: anatomy, normal, or pathologic endovaginal imaging and normal or pathologic endoanal imaging (P

OBJECTIVE: To compare the sensitivity and specificity of two- (2D) and three- (3D) dimensional transperineal ultrasound (TPUS) and 3D endovaginal ultrasound (EVUS) with the gold standard 3D endoanal ultrasound (EAUS) in detecting residual defects after primary repair of obstetric anal sphincter injuries (OASIS). METHODS: External (EAS) and internal (IAS) anal sphincters were evaluated by the four ultrasound modalities in women with repaired OASIS. 2D-TPUS was evaluated in real-time, whereas 3D-TPUS, 3D-EVUS and 3D-EAUS volumes were evaluated offline by six blinded readers. The presence/absence of any tear in EAS or IAS was recorded and defects were scored according to the Starck system. Sensitivity, specificity and predictive values were calculated, using 3D-EAUS as reference standard. Inter- and intraobserver analyses were performed for all 3D imaging modalities. Association between patients' symptoms (Wexner score) and ultrasound findings (Starck score) was calculated. RESULTS: Images from 55 patients were analyzed. Compared with findings on 3D-EAUS, the agreement for EAS evaluation was poor for 3D-EVUS (? = 0.01), fair for 2D-TPUS (? = 0.30) and good for 3D-TPUS (? = 0.73). The agreement for IAS evaluation was moderate for both 3D-EVUS (? = 0.41) and 2D-TPUS (? = 0.52) and good for 3D-TPUS (? = 0.66). Good intraobserver (3D-EAUS, ? = 0.73; 3D-TPUS, ? = 0.78) and interobserver (3D-EAUS, ? = 0.68; 3D-TPUS, ? = 0.60) agreement was reported. Significant association between Starck and Wexner scores was found only for 3D-EAUS (Spearman's rho = 0.277, P = 0.04). CONCLUSIONS: 2D-TPUS and 3D-EVUS are not accurate modalities for the assessment of anal sphincters after repair of OASIS. 3D-TPUS shows good agreement with the gold standard 3D-EAUS and a high sensitivity in detecting residual defects. It, thus, has potential as a screening tool after primary repair of OASIS. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

The terminology for anorectal dysfunction in women has long been in need of a specific clinically-based Consensus Report. This Report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted on Committee by experts in their fields to form a Joint IUGA/ICS Working Group on Female Anorectal Terminology. Appropriate core clinical categories and sub classifications were developed to give an alphanumeric coding to each definition. An extensive process of twenty rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). A Terminology Report for anorectal dysfunction, encompassing over 130 separate definitions, has been developed. It is clinically based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Female-specific anorectal investigations and imaging (ultrasound, radiology and MRI) has been included whilst appropriate figures have been included to supplement and help clarify the text. Interval review (5–10 years) is anticipated to keep the document updated and as widely acceptable as possible. A consensus-based Terminology Report for female anorectal dysfunction terminology has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

The pelvic floor is a complex, three-dimensional mechanical apparatus that consists of several components: the pelvic organs and endopelvic fascia, the ligament and perineal membrane, the levator ani muscles and superficial perineal muscles, and the pelvic nerves. The support for the pelvic organs comes from connections to the bony pelvis and its attached muscles. Any damage to the structural and functional interactions of the pelvic floor elements can potentially cause multicompartmental dysfunction. Surgical management of pelvic floor disorders depends on a comprehensive understanding of the structural integrity and function of the pelvic floor. As a result of technological progress, dedicated imaging modalities including static and dynamic 3D and 4D transvaginal, endoanal and transperineal ultrasound, dynamic Magnetic Resonance, and evacuation proctography have been introduced. The "integrated" use of these techniques provides outstanding visualization of the anatomy of the pelvic floor, allowing for accurate assessment of the major disorders—urinary and fecal incontinence, pelvic organ prolapse, and obstructed defecation syndrome.

INTRODUCTION AND HYPOTHESIS: The aim was to analyze the correlation between residual anal sphincter (AS) defects and pelvic floor muscle (PFM) strength on anal incontinence (AI) in patients with a history of obstetric AS injuries (OASIS). METHODS: From September 2012 to February 2015, an observational study was conducted on a cohort of females who underwent repair of OASIS intrapartum. The degree of OASIS was scored intrapartum according to Sultan's classification. Participants were assessed at 6 months postpartum. Incontinence symptoms were evaluated using Wexner's score and PFM strength using the Modified Oxford Scale (MOS). 3D-endoanal ultrasound was performed to classify AS defects according to Starck's system. Correlation between Sultan's and Starck's classifications was calculated using Cohen's kappa and Spearman's rho (R(s)) test. The impact of residual AS defects and PFM strength on AI was analyzed using a multiple regression model. RESULTS: A total of 95 women were included in the study. Good correlation (?= 0.72) was found between Sultan's and Starck's classifications. Significant positive correlation was observed between Wexner's score and both Sultan's (p = 0.023, R(s) =0.212) and Starck's (p < 0.001, R(s) =0.777) scores. The extent of the residual AS defect was the most relevant factor correlating with AI symptoms. In patients with severe AS injuries, higher MOS values were associated with lower Wexner's score. CONCLUSIONS: The degree of AS tear measured intrapartum was the most important factor related to AI after primary repair of OASIS. PFM strength was associated with lower incontinence symptoms in the postpartum period.

Ultrasound scanning plays an important role in evaluating the extent of benign and malignant anorectal and pelvic diseases. This chapter discusses this important method for evaluating rare anorectal and pelvic neoplasias, one which allows for the quantification of the exact circumferential and longitudinal extension of the lesion into the rectal wall or adjacent tissue and the relation between the lesion and the sphincter muscles. This is the most important aspect to consider when planning surgical resection with or without sphincter-saving. In addition, the three-dimensional scanning mode is safer, making it possible to review the images posteriorly, in real time, as required by some lesions.

Endoanal ultrasound imaging is the gold standard for visualization of anal sphincter complex. High resolution 3D ultrasonography has further enhanced our understanding of anal sphincter anatomy. The new technology has enabled the practitioner to investigate perianal abscesses, defecatory dysfunction, and other benign pathologies.

Background Organic or functional anal canal stenoses are uncommon conditions that occur in the majority of cases as a consequence of anal diseases. A proper assessment is fundamental for decision making; however, proctological examination and endoanal ultrasound are often unfeasible or very difficult to perform even under local or general anesthesia. We therefore began to use 3D transperineal ultrasound to assess patients. The aim of this study was to compare the results of evacuation proctography and 3D transperineal ultrasound in patients with severe anal canal stenosis. Methods Four consecutive patients with high-grade anal canal stenosis were evaluated using both proctography and 3D transperineal ultrasound with a micro-convex transducer between March and June 2011. Results In all cases, 3D transperineal ultrasound provided detailed information on the length and level of stenosis and on the integrity of the anal sphincters. Conclusions Our preliminary experience suggests that 3D transperineal ultrasound makes it possible to plan optimal surgical treatment.

To assess the vascular parameters in the urethra of nulliparous females and to compare the vascularity among various parts of the urethra, using high-frequency endovaginal ultrasonography (EVUS).Twenty-two nulliparous women, mean age 27 years, underwent EVUS using a biplane transducer at 12 MHz frequency. Color Doppler examinations of the urethra were recorded and further evaluated off-line using special software (Pixel Flux) for quantitative assessment of the vascularity. The urethra was divided into four regions of interest (ROIs) in the midsagittal plane and three ROIs in the axial plane. The following parameters were measured: velocity (V), perfused area (A), perfusion intensity (I), pulsatility index (PI), and resistance index (RI). Interobserver and intraobserver reproducibility analysis was also performed.In midsagittal plane, the midurethra presented the highest value of V and lowest value of A. The intramural part showed the lowest value of I and the highest values of RI and PI. In the distal urethra, the highest value of I and the lowest value of RI was seen. In the axial plane, the values of V, A, and I were statistically significantly higher in the external part of the midurethra compared with the internal part. Excellent interobserver and intraobserver reproducibility was shown in the majority of parameters for the entire urethra.Vascularity differs in different parts of the urethra. Pixel Flux is a valuable tool for providing reproducible quantitative analysis of vascular parameters for the entire urethra.

The paper presents the role of various ultrasound modalities in the diagnostics of female pelvic floor disorders (PFD). It describes the use of two/three/four-dimensional transperineal ultrasound and endocavitary transducers, which, up to now, have been used for proctological examinations and prostate cancer brachytherapy. Ultrasonography is the most widely available imaging modality. As a result of technical progress, novel transducers and more sophisticated software have recently been introduced to the market providing more information about the anatomy of pelvic organs. Some features of these transducers, such as higher frequency and multiplanar imaging, enable better visualisation of pelvic floor organs. In-depth knowledge of the technical and physical properties of modern ultrasonography, as well as its advantages and limitations, could provide an integrated approach to imaging of PFD. Technical modalities, the wide availability of ultrasonographic techniques, and an understanding of the imaging possible with modern ultrasonography could improve our understanding of PFD and allow better assessment in pre- and post-surgical management.

Surgical management of pelvic floor disorders depends on a comprehensive understanding of the structural integrity and function of the pelvic floor. For visualizing this region, ultrasonography has emerged as a procedure that is relatively easy to perform, cost-effective and widely available. In this review, pelvic floor ultrasonography, including two-dimensional (2D), three-dimensional (3D) and 4D imaging as well as transvaginal, endoanal and transperineal techniques, is discussed from a global and multicompartmental perspective, rather than using a compartmentalized approach. The role of the different sonographic modalities in the major disorders of the pelvic floor-urinary and fecal incontinence, pelvic organ prolapse and obstructed defecation syndrome-is evaluated critically.

the study aims were to evaluate (1) the interobserver and (2) the interdisciplinary repeatability of levator hiatus, urethral thickness, and anorectal angle measurements using three-dimensional endovaginal ultrasound (3D-EVUS).twenty-seven nulliparous asymptomatic females were imaged with 3D-EVUS. Analyses were conducted off-line from stored 3D volumes by six readers (two radiologists, two urogynecologists, and two colorectal surgeons) using a standardized technique. Reproducibility was determined using the interclass correlation coefficients (ICC).the overall interobserver repeatability for levator hiatus dimensions was good to excellent (ICC, 0.655-0.889), for urethral thickness was good (ICC, 0.624), and for anorectal angle was moderate (ICC, 0472). The interdisciplinary repeatability for levator hiatus indices was good to excellent (ICC, 0.639-0.915), for urethral thickness was moderate to good (ICC, 0.565-0.671), and for anorectal angle was fair to moderate (ICC, 0.204-0.434).3D-EVUS yields reproducible measurements of levator hiatus dimensions and urethral thickness in asymptomatic nulliparous women.

The pelvic floor is a complex, three-dimensional (3D) mechanical apparatus that has been artificially divided in three different regions: anterior, middle, and posterior compartments. However, urinary (urinary incontinence, voiding dysfuntion, cystocele), genital (uterine prolapse, vaginal vault prolapse, enterocele), and anorectal abnormalities (fecal incontinence, obstructed defecation, rectocele, intussusception, dyssynergia) are frequently associated in women with pelvic floor dysfunction [1]. Although patients may present with symptoms that involve only one compartment, 95% of patients have abnormalities in all three compartments [2]. As a consequence, the specialist (urologist, gynecologist, gastroenterologist, and colorectal surgeon) approaching the pelvic floor should not have vertical vision confined to their area of interest, but a transverse, multicompartmental vision, always taking into consideration that pelvic floor disorders rarely occur in isolation.

The presence of endometriosis in the anal canal and perianal tissues is rare and difficult to suspect at clinical examination. We report our experience with preoperative ultrasound evaluation of four cases of anal endometriosis. Four patients were evaluated by transperineal and high-resolution three-dimensional endoanal ultrasonography. In 3 of 4 women, the lesions involved old episiotomy scars. Anal endometriosis appeared as hypoechoic cystic lesions with areas of microcalcification, not well delimited and highly vascularized. The lesions either involved the anal sphincter (n = 2, one within the rectovaginal septum) or were localized superficially in the ischiorectal space (n = 2). Surgery and pathologic exam confirmed the ultrasonographic findings. Ultrasonographic findings of anal endometriosis are characteristics and may allow accurate preoperative staging of the disease.

Anorectal imaging has become an integral part of the assessment of posterior compartment disorders. Following detailed history and examination, the patient should be offered anal sphincter imaging (either 2D or 3D endoanal ultrasonography). Even though anorectal physiological studies indicate dysfunction of the anal sphincter complex, they do not identify the anatomical site and the degree of anal sphincter disruption. Endoanal ultrasound has been defined the gold standard investigation for detecting anal sphincter injuries in fecal incontinence and it is also used in the follow-up after primary sphincter repair or injection of bulking agents. Endoanal ultrasound represents a good modality for the preoperative and intraoperative investigation of perianal abscesses and fistulas and may guide the surgical treatment. In recent years, echodefecography has been developed as alternative to defecography and dynamic MRI for the evaluation of obstructed defecation syndrome and posterior vaginal wall prolapse.

Ultrasound scanning plays an important role in evaluating the extent of benign and malignant anorectal and pelvic diseases. This chapter discusses about this important method for evaluating rare anorectal and pelvic neoplasias and allows to quantify the exact circumferential and longitudinal extension of the lesion into rectal wall or adjacent tissue and the relation between the lesion and the sphincter muscles. This is the most important aspect to consider when planning surgical resection with or without sphincter saving. In addition, the three-dimensional scanning mode is safer as it makes it possible to review the images posteriorly, in real time, as required by some lesions.

Imaging of the rectum, anorectal junction, and surrounding tissues has always been challenging, including technically, especially when conventional radiological techniques such as computed tomography (CT) and barium studies are used. However, during the past few decades, magnetic resonance imaging (MRI) and sonography have significantly improved visualization of the anorectum and of perianal diseases.

As discussed elsewhere in this volume, transanal ultrasound is a simple, rapid and minimally invasive procedure that can accurately detect and classify perianal fistulas and their complications. It is also useful to monitor patients after treatment, to guide their management. To date, the scientific literature is generally positive regarding the usefulness of transanal and transperineal ultrasound in assessing perianal disease. However, it is also well known that the magnitude of accuracy of these techniques may vary, depending on the complexity of perianal disease considered in the published series and the expertise of the investigators, since transanal and transperineal ultrasound are operator-dependent procedures; both are therefore vulnerable to pitfalls and have specific disadvantages, considered below.

Endoanal ultrasonography (EAUS) is important in patients with fecal incontinence (FI) to differentiate between incontinent patients with intact anal sphincters and those with sphincter lesions (defects, scarring, thinning, thickening, and atrophy). High-resolution multiplanar reconstructions and rendering techniques further enhance the accuracy of EAUS. Ultrasonographic findings may lead to appropriate therapy (sphincteroplasty, graciloplasty, injection of bulking agents, sacral nerve stimulation), and the technique also serves as a surveillance tool to monitor results following surgical treatment. In addition, detection of occult tears after vaginal delivery may have a role in the prevention of FI, with a recommendation that women at increased risk have an elective cesarean section.

Continence depends on a number of factors that include stool consistency, the capacity of the sigmoid colon to retard progress of stool, the compliance and sensation of urgency of the rectum, phasic contractions of the puborectalis muscle to form a normal anorectal angle, a normal internal (IAS) and external anal sphincter (EAS) function, and normal sensation in the anal canal [1, 2, 3].

High-resolution three-dimensional endoanal ultrasonography (3D-EAUS) clearly demonstrates the anatomy of the anal canal. All relevant structures, including the puborectalis muscle, the internal and external sphincter, the conjoined longitudinal layer, and the transverse perinei muscles, are visualized and any sphincter disruptions or defects can be detected. The asymmetrical shape of the anal canal and the gender differences in the ventral part of the external sphincter are also easily evaluated in the different reconstructed planes of the three-dimensional volume. High-resolution threedimensional endorectal ultrasound (3D-ERUS) provides an accurate visualization of the five-layer structure of the rectal wall and of the all pelvic organs adjacent to the rectum. The purpose of this chapter is to present the technique of 3D-EAUS and 3DERUS and to revise the ultrasonographic anatomy of the anorectal region.