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Background: Patient selection is extremely important in obstructed defecation syndrome (ODS) and rectal prolapse (RP) surgery. This study assessed factors that guided the indications for ODS and RP surgery and their specific role in our decision-making process using a machine learning approach. Methods: This is a retrospective analysis of a long-term prospective observational study on female patients reporting symptoms of ODS who underwent a complete diagnostic workup from January 2010 to December 2021 at an academic tertiary referral center. Clinical, defecographic, and other functional tests data were assessed. A supervised machine learning algorithm using a classification tree model was performed and tested. Results: A total of 400 patients were included. The factors associated with a significantly higher probability of undergoing surgery were follows: as symptoms, perineal splinting, anal or vaginal self-digitations, sensation of external RP, episodes of fecal incontinence and soiling; as physical examination features, evidence of internal and external RP, rectocele, enterocele, or anterior/middle pelvic organs prolapse; as defecographic findings, intra-anal and external RP, rectocele, incomplete rectocele emptying, enterocele, cystocele, and colpo-hysterocele. Surgery was less indicated in patients with dyssynergia, severe anxiety and depression. All these factors were included in a supervised machine learning algorithm. The model showed high accuracy on the test dataset (79%, p < 0.001). Conclusions: Symptoms assessment and physical examination proved to be fundamental, but other functional tests should also be considered. By adopting a machine learning model in further ODS and RP centers, indications for surgery could be more easily and reliably identified and shared. [ABSTRACT FROM AUTHOR]

Background Anismus is a functional disorder characterized by dyssynergia and incoordination of pelvic floor muscular contractions at defecation. Despite normal propulsive power used when attempting to defecate, a hypertonic pelvic floor dysfunction results in nonrelaxation or even paradoxical contraction of puborectalis muscle, resulting in failure to straighten the anorectal angle, hence impaired stool evacuation. This study aims at evaluating the outcome of injection of botulinum toxin type-A (BTX-A) in puborectalis muscle in patients with anismus. Patients and methods The study included 50 patients who were presented with symptoms of obstructed defecation (OD) and were diagnosed as anismus and failed conservative treatment and biofeedback training. Ultrasound-guided BTX-A injections into puborectalis muscle were done. All patients were followed up for 6 months for OD symptoms and manometric findings. Results The current study included 50 patients with a mean age of 36.6±11.9 years presented with anismus for a mean duration of 6.8±2.64 months. There was a statistically significant improvement in the Longo score of OD at 1, 3, and 6 months when compared with the initial values (P<0.001), while there was no statistically significant difference noticed in the defecation frequency at 3 and 6 months when compared with the initial records. There was a statistically significant decrease in both resting and squeeze pressures after 3 and 6 months when compared with the initial records (P<0.001). The overall satisfaction significantly increased to 68 and 64% after 3 and 6 months, respectively, when compared with 0% satisfaction reported at the initial assessment. Conclusion According to the current results, injection of BTX-A therapy in puborectalis muscle in patients with anismus is assumed to be effective for short term with good overall satisfaction. [ABSTRACT FROM AUTHOR]

Introduction: Obstetric anal sphincter injury is an important risk factor for postpartum fecal incontinence but few studies have reported fecal incontinence occurring, even during pregnancy. The first objective of this study was to examine the prevalence of fecal incontinence, obstructed defecation and vaginal bulging early and late in pregnancy and postpartum. The second objective was to assess the association between symptoms in pregnancy, delivery characteristics, and bowel and vaginal bulging symptoms at 1 year postpartum. Material and methods: This prospective cohort study was conducted between October 2014 and October 2017, including 898 nulliparous women enrolled with the maternity healthcare service in Örebro County, Sweden. The women responded to questionnaires regarding pelvic floor dysfunction in early and late pregnancy and at 8 weeks and 1 year postpartum. The data were analyzed using random effect logistic models estimating odds ratios (ORs) and generalized linear models estimating relative risks, with 95% confidence intervals (CIs). Results: At 1 year postpartum, the prevalence of fecal incontinence, obstructed defecation and vaginal bulging was 6% (40/694), 28% (197/699) and 8% (56/695), respectively. Among women with vaginal delivery, the risk of fecal incontinence and vaginal bulging increased significantly both in late pregnancy, with ORs of 3.4 (95% CI 1.5–7.7) and 3.6 (95% CI 1.6–8.1), respectively, and at 1 year postpartum, with ORs of 5.0 (95% CI 2.1–11.5) and 8.3 (95% CI 3.8–18.1), respectively, compared with early pregnancy. Among all women, factors associated with increased prevalence of fecal incontinence 1 year postpartum were fecal incontinence during pregnancy (adjusted relative risk [aRR] 7.4; 95% CI 4.1–13.3), obstructed defecation during pregnancy (aRR 2.0; 95% CI 1.1–3.9) and concurrent obstructed defecation (aRR 2.4; 95% CI 1.3–4.5). Conclusions: This prospective study shows an increased risk of fecal incontinence by late pregnancy, suggesting that the pregnancy itself may be involved in the development of postpartum fecal incontinence. Obstructed defecation during pregnancy and postpartum was found to be associated with increased risk of fecal incontinence postpartum, indicating that postpartum fecal incontinence may be a result of incomplete bowel emptying. [ABSTRACT FROM AUTHOR]

Objective Pelvic floor dysfunction can manifest as a spectrum including anorectal dysfunction, vaginal prolapse, and urinary incontinence. Sacrospinous fixation is a procedure performed by gynecologists to treat vaginal prolapse. The present study aims to evaluate the impact of transvaginal prolapse surgery on anorectal function. Materials and Methods We conducted a retrospective review of patients undergoing sacrospinous fixation surgery for vaginal prolapse between 2014 to 2020. Those with anorectal dysfunction who had also been evaluated by the colorectal service preoperatively and postoperatively were included for analysis. These patients were assessed with symptom-specific validated questionnaires. The effect of surgery on constipation and fecal incontinence symptoms was analyzed. Results A total of 22 patients were included for analysis. All patients underwent transvaginal sacrospinous fixation, and 95.4% also had posterior colporrhaphy for vaginal prolapse. There were a statistically significant improvements in the Fecal Incontinence Severity Index (FISI), the St. Mark's Incontinence Score (Vaizey), the embarrassment and lifestyle components of the Fecal Incontinence Quality of Life Score, the Constipation Scoring System, the Obstructed Defecation Score, and components of the Patient Assessment of Constipation Quality of Life score. Conclusion Transvaginal prolapse surgery leads to a favorable effect on anorectal function, with improvements in both obstructed defecation and fecal incontinence scores in this small series.

Anismus or non-relaxing puborectalis muscle (PRM) on straining may affect over 40% of patients with obstructed defecation (OD). Management is usually with biofeedback, or botulin toxin injection or partial puborectalis muscle myotomy. Such a procedure can be difficult technically. Bleeding and rectal injury may occur when detaching the PRM from the rectum. A partial modification of surgical technique may avoid these complications. The diagnosis should be confirmed with exclusion of sphincter compromise. Through two cutaneous incisions, an Ellis forceps is advanced through the ischio-rectal space, whilst finger pressure per rectum allows the puborectalis to be visualized and grasped by the forceps. Removal of some ischiorectal fat may be necessary to allow division of half the PRM under direct view. From October 2020 to October 2021, 5 patients underwent the modified technique in our department (4 males, median age 43 years [range 34–58 years], median follow-up 6 months [range 2–12 months]). No patients suffered from injury of the rectum or bleeding during or after surgery. Operative time was 30 min less than conventional PRM division, as the time-consuming "blind dissection" of PRM was avoided. Four patients regained appropriate relaxation of the PRM on straining. One male patient had temporary minor anal incontinence for 2 weeks. One male patient with severe mental distress continued to have with anismus and OD after surgery and refused psychiatric support. This modified procedure is feasible and safe and quicker than our conventional technique. More cases with longer follow-up are needed to confirm its efficacy. [ABSTRACT FROM AUTHOR]

Abstract Background Functional obstructed defecation is a common anorectal problem among adult population. The objective was to compare the short-term efficacy of biofeedback pelvic floor muscle training versus transcutaneous posterior tibial nerve electrostimulation in treatment of patients with functional obstructed defecation. Results There were 41 patients completed the study. There were no statistical significant differences between biofeedback pelvic floor muscle training group and transcutaneous posterior tibial nerve electrostimulation group regarding different clinical characteristics, as well as, electrophysiological findings. There was statistically significant reduction in all outcome measures after intervention in both groups. The primary outcome measure was Modified obstructed defecation score. Secondary outcome measures were Patient Assessment of Constipation-Quality of Life questionnaire, time of toileting, and maximum anal pressure during straining to evacuate. No significant differences were present between both groups regarding different outcome measures in the pretreatment and post-treatment assessments. Successful outcome was reported in 81% of patients in biofeedback pelvic floor muscle training group in comparison to 40% of patients in the posterior tibial nerve electrostimulation group according to the Modified obstructed defecation score which was the primary outcome measure. Conclusions Both biofeedback pelvic floor muscle training and posterior tibial nerve electrostimulation are considered effective methods in the treatment of functional obstructed defecation. However, biofeedback pelvic floor muscle training seems to be more effective and superior in comparison to posterior tibial nerve electrostimulation. Posterior tibial nerve electrostimulation could be combined with biofeedback pelvic floor muscle training or considered as a second line therapy after failure of biofeedback pelvic floor muscle training. Trial registration Pan African Clinical Trials Registry, PACTR202009762113535. Registered 2 September 2020—retrospectively registered, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12321 .

APFUS = endoanal/endorectal pelvic floor ultrasound; EAS = external anal sphincter; IAS = internal anal sphincter Important caveats in the imaging include the following: 1) identification of the puborectalis muscles immediately cephalad to the anal sphincter; 2) differentiation of an anterior external sphincter injury versus a short anal sphincter in a female in the middle anal canal; 3) recognition that the distal anal canal only contains external sphincter; and 4) and a thinned out perineal body may be a sign of middle anal sphincter injury. Keywords: Anal incontinence; Anal sphincter; Anorectal tumors; Dyspareunia; Fecal incontinence; Levator ani muscle; Obstetric perineal injury; Obstructed defecation; Pelvic floor; Pelvic organ prolapse; Perianal abscess and fistula; Synthetic implants; Ultrasound; Urinary incontinence EN Anal incontinence Anal sphincter Anorectal tumors Dyspareunia Fecal incontinence Levator ani muscle Obstetric perineal injury Obstructed defecation Pelvic floor Pelvic organ prolapse Perianal abscess and fistula Synthetic implants Ultrasound Urinary incontinence 603 619 17 02/24/23 20230301 NES 230301 Jonia Alshiek, Sthela M. Murad-Regadas, and Anders Mellgren contributed equally as first coauthors. APFUS = endoanal/endorectal pelvic floor ultrasound; AR = anorectum; EAS = external anal sphincter; IAS = internal anal sphincter; L = left; LP = levator plate; P = posterior; PC = pubococcygeus; PR = puborectalis; R = right; V = vagina When an anal sphincter injury is suspected, complete characterization of the injury requires... Obstetric anal sphincter injury is a common cause of fecal incontinence [[30]]. 1:STN:280:DC%2BD387hvFGitw%3D%3D. 10.1007/s10350-004-6140-1. 11852329 24 Sultan AH, Thakar R. Diagnosis of anal sphincter tears to prevent fecal incontinence: a randomized controlled trial. [Extracted from the article]

Anatomic or functional pelvic floor dysfunction leads to obstructed defecation syndrome which is characterized by chronic constipation leading to difficulty in evacuation. It has an adverse impact on patients' quality of life. Herein, we present an unusual case of a young patient with obstructive defecation and severe pain posing a diagnostic and therapeutic challenge. After failure of conservative efforts, he was investigated further by magnetic resonance defecography. A nodular lump involving the internal sphincter and part of the external sphincter was detected. He underwent a wide excision of the lump along with part of the external and internal sphincter. Histopathology was suggestive of a chronic inflammatory nodule with fibrosis. On a 6-month follow-up, patients' symptoms had completely subsided, and his quality of life significantly improved. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Obstructed defecation (OD) is often associated with trauma to pelvic connective tissue and nerves sustained during pregnancy and childbirth. Although there are multiple potential etiologies of defecatory dysfunction, the pathophysiology of this symptom complex is not well understood. The purpose of this study is to determine the role of parity in the development of obstructed defecatory symptoms in women with normal anorectal anatomy in a search for evidence of a presumptive neuropathic effect of pregnancy and childbirth. Methods: This study retrospectively evaluated the records of 754 women presenting at a tertiary urogynecology unit for pelvic floor dysfunction with no anatomical abnormalities of the anorectum on imaging. They were stratified according to parity. The authors determined the prevalence of obstructed defecation symptoms in these groups. Chi-squared test was performed for statistical analysis. Results: Median age was 51 (range 16–88) years, and median vaginal parity was 2 (0–8); 399 (53%) women reported symptoms of OD. When anatomical abnormalities of the anorectum were excluded, parity did not seem to have a major effect on the prevalence of symptoms of OD. Conclusions: In this cohort, parity is unlikely to be a cause of OD in women with normal anorectal anatomy. [ABSTRACT FROM AUTHOR]

ABSTRACT BACKGROUND: Few studies have investigated the constipation or obstructed defecation symptoms identified by using imaging, as dynamic three-dimensional ultrasound and correlate vaginal delivery, parity, and age. OBJECTIVE: The aim of this study was to assess the prevalence of pelvic floor dysfunctions in female patients with obstructed defection symptoms and to determine whether specific pelvic floor dysfunctions identified by dynamic three-dimensional ultrasonography (echodefecography) are correlated with vaginal delivery, parity, and age. The secondary goal is to report the prevalence of coexisting pelvic floor dysfunctions. METHODS: This is a retrospective cohort study including patients with obstructed defecation symptoms underwent echodefecographyto evaluate pelvic floor dysfunctions in the posterior compartment and correlate with vaginal delivery, parity, and age. RESULTS: Of 889 female: 552 (62%) had had vaginal delivery and 337 (38%) were nulliparous. The prevalence of dysfunctions identified by echodefecography (rectocele, intussusception, enterocele/sigmoidocele, and dyssynergia) was similar between the two groups and was not associated with number of deliveriesor age. However, the prevalence of sphincter defects showed higher rates in women with vaginal delivery and increased with the parity. Up to 33% of patients had coexisting dysfunctions. CONCLUSION: The prevalence of dysfunctions such as rectocele, intussusception, dyssynergia, and enterocele/sigmoidocele assessed by echodefecography in patients with obstructed defecation symptoms are found similar regardless of vaginal delivery, number of deliveries or stratified-age. In vaginal delivery, number of deliveries does impact on detection of sphincter defects and liability to fecal incontinence.

Purpose: This study aimed to investigate the relationship between postoperative anxiety/depression and functional outcomes of laparoscopic ventral rectopexy (LVR) for obstructed defecation (OD). Methods: Patients who received LVR for OD between March 2014 and July 2020 were enrolled. Patient demographics were recorded before surgery. The validated Cleveland Clinic Constipation Score (CCCS) and Patient Assessment of Constipation Quality of Life (PAC-QoL) were evaluated to assess functional outcomes and QoL, respectively. The self-rating anxiety scale and self-rating depression scale were used to measure anxiety and depression, respectively. Results: Twenty-five patients were recruited. Significant improvement was found at last available follow-up (LAFU) in CCCS (P = .001), and three PAC-QoL subsets, physical discomfort (P = .003), satisfaction (P = .014), and worries/concerns (P = .033) during follow-up of 60 (11-84) months. In the patients with anxiety/depression (n = 11), significant improvement was found at LAFU in CCCS (P = .024) and the PAC-QoL subset, psychosocial discomfort (P = .038). In the patients without anxiety/depression (n = 14), improvement was found in CCCS (P = .009) and the PAC-QoL subset, physical discomfort (P = .018). Conclusion: The long-term functional outcomes of LVR for OD in patients with overt pelvic structural abnormalities are not undermined by postoperative anxiety/depression. [ABSTRACT FROM AUTHOR]

Abstract Background Obstructed defecation is a common pelvic floor medical problem among adult population. Pelvic floor disorders were reported to be associated with sexual dysfunction including erectile dysfunction among male patients. The aim was to determine the relation between pelvic floor neurophysiological abnormalities and erectile dysfunction in male patients with obstructed defecation. Methods This cross-sectional study included 65 married male patients with obstructed defecation and a control group consisted of 15 apparently healthy married males. Assessment of obstructed defecation severity was done by using modified obstructed defecation score, time of toileting and Patient Assessment of Constipation-Quality of Life questionnaire. Assessment of erectile functions was done using erectile function domain of International Index of Erectile Function questionnaire and Erectile Dysfunction-Effect on Quality of Life Questionnaire. Anal manometry and dynamic pelvis magnetic resonance imaging were done. Electrophysiological studies included pudendal nerve motor conduction study and needle electromyography of external anal sphincter, puborectalis and bulbocavernosus muscles. Results There were 32 patients (49.2%) who had erectile dysfunction. The maximum straining anal pressure was significantly higher among patients with erectile dysfunction. Pudendal nerve terminal motor latency was significantly delayed and the percentage of bilateral pudendal neuropathy was significantly higher among patients with erectile dysfunction. The percentage of electromyography evidence of denervation with chronic reinnervation in the external anal sphincter and bulbocavernosus muscles were significantly higher among patients with erectile dysfunction. Regression analysis detected three co-variables to be associated with significantly increasing the likelihood of development of erectile dysfunction. These were maximum straining anal pressure (odd ratio = 1.122), right pudendal nerve terminal motor latency (odd ratio = 3.755) and left pudendal nerve terminal motor latency (odd ratio = 3.770). Conclusions Erectile dysfunction is prevalent among patients with obstructed defecation. It is associated with characteristic pelvic floor electrophysiological abnormalities. Pelvic floor neurophysiological changes vary from minimal to severe neuromuscular abnormalities that usually accompanying erectile dysfunction. Pudendal neuropathy and increased maximum straining anal pressure are essential risk factors for increasing the likelihood of development of erectile dysfunction in patients with obstructed defecation.

Abstract Objective The aim of this study is to examine the relationship between rectal–vaginal pressure and symptomatic rectocele in patients with pelvic organ prolapse (POP). Method Patients with posterior vaginal prolapse staged III or IV in accordance with the POP Quantitation classification method who were scheduled for pelvic floor reconstructive surgery in the years 2016–2019 were included in the study. Rectocele was diagnosed using translabial ultrasound, and obstructed defecation (OD) was diagnosed in accordance with the Roma IV diagnostic criteria. Both rectal and vaginal pressure were measured using peritron manometers at maximum Vasalva. To ensure stability, the test was performed three times with each patient. Results A total of 217 patients were enrolled in this study. True rectocele was diagnosed in 68 patients at a main rectal ampulla depth of 19 mm. Furthermore, 36 patients were diagnosed with OD. Symptomatic rectocele was significantly associated with older age (p 27.5 cm H2O was suggested as the cut-off point of the elevated pressure gradient.

Background: The aim of this study was to compare patients' mid-term functional and quality of life (QoL) outcomes following robotic ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR). Methods: The data of consecutive female patients who underwent minimally invasive ventral mesh rectopexy for external or symptomatic internal rectal prolapse at 3 hospitals in Finland between January 2011 and December 2016 were retrospectively collected. Patients were matched by age and diagnosis at a 1:1 ratio. A disease-related symptom questionnaire was sent to all living patients at follow-up in July 2018. Results: After a total of 401 patients (RVMR, n = 187; LVMR, n = 214) were matched, 152 patients in each group were included in the final analyses. The median follow-up times were 3.3 (range 1.6–7.4) years and 3.0 (range 1.6–7.6) years for the RVMR and LVMR groups, respectively. The postoperative QoL measures did not differ between the groups. Compared with the LVMR group, the RVMR group had lower postoperative Wexner Incontinence Score (median 5 vs. median 8; p < 0.001), experienced significant ongoing incontinence symptoms less often (30.6% vs. 49.0%; p < 0.001) and reported less postoperative faecal incontinence discomfort evaluated with the visual analogue scale (median 11 vs. median 39; p = 0.005). RVMR patients had a shorter hospital stay (2.2 days vs. 3.8 days; p < 0.001) but experienced more frequent de novo pelvic pain (31.8% vs. 11.8%; p < 0.001). Conclusion: RVMR and LVMR patients had equal functional and QoL outcomes. Those who underwent RVMR had lower mid-term anal incontinence symptom scores but suffered more frequent de novo pelvic pain. [ABSTRACT FROM AUTHOR]

Objectives: The management of pelvic floor dysfunction (PFD) is challenging because of high failure rates after surgery. The objective of this study was to compare the combined surgical treatment for complex PFD versus single procedures to improve the outcome. Materials and Methods: A prospective series of consecutive patients (n=30) undergoing single pelvic procedure (SP group) was compared to patients (n=30) operated with combined procedure (CP group) over a 24-month period in a tertiary referral university center in Italy. The primary outcome was the overall rate of PFD recurrence and "de novo" PFD at 24-months after surgery. Secondary outcomes included postoperative complications, functional outcomes, quality of life, and patient satisfaction. Results: At 24-months after surgery, we observed more recurrences in the SP group compared to CP group (6.7% vs 3.3%). De novo defects occurred more frequently in the SP group than in CP group (30% vs 6.7%; p=0.022). Ten percent of women of SP group underwent further surgery, compared to 3% in the CP group. Minor complications occurred in 33.3% of women in SP group and 43.3% in CP group. Postoperative improvement of pelvic prolapse was better in CP group (p=0.009). PFDI and PFQI questionnaires revealed significant postoperative clinical and quality-of-life improvement (p<0.0001) in both groups. Defecatory symptoms improved significantly in CP group (p=0.049). Minor fecal incontinence worsened in CP group while urinary symptomatology resulted improved in both groups. Patient satisfaction was very good in both groups. Conclusion: The combined surgical approach to PFD is effective and safe. [ABSTRACT FROM AUTHOR]

Introduction and hypothesisWe hypothesized that there would be a significant difference in changes in obstructed defecation symptoms and posterior compartment prolapse between women who underwent posterior vaginal wall prolapse repair (PR) and those who did not.MethodsThis was a two-site prospective cohort study of women undergoing prolapse or incontinence surgery in which a PR was, or was not, performed at the discretion of the surgeon. Women were assessed using validated obstructed defecation questionnaires and standardized examination measures (including POP-Q, measurement of transverse gh, and assessment for a rectovaginal pocket and laxity) prior to pelvic surgery and 12 weeks after surgery.ResultsOf 68 women who underwent surgery, 43 had PR. The PR group had higher obstructed defecation symptoms and greater posterior compartment prolapse at baseline. At 12 weeks, obstructed defecation symptoms had improved significantly more in the PR group than in the no PR group (all p

Introduction and hypothesis: The primary aim of this study was to assess for an association between maximal intra-abdominal pressure reached on Valsalva (MAP) and pelvic organ prolapse (POP) on subjective, clinical and sonographic evaluation. Another objective was to test for association between MAP and body mass index (BMI). Methods: A retrospective cross-sectional study was carried out on 504 archived datasets of women seen for pelvic floor dysfunction symptoms between January 2017 to September 2019 at a tertiary urogynaecology clinic. Patients underwent a standardized interview including use of visual analogue scores (VAS) to evaluate bother of pelvic floor symptoms, examination using the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q), dual-channel filling and voiding cystometry, test for MAP as well as four-dimensional (4D) transperineal ultrasound. Analysis of ultrasound volumes for pelvic organ descent was performed blinded against all other data. Results: There was a weak but significant association between MAP and sonographic rectal ampulla descent (p = 0.0275). There was also a significant association between MAP and bother of obstructed defecation symptoms (p = 0.0065). Symptomatic, clinical and sonographic POP in the anterior or the apical compartments was not significantly associated with MAP. On multivariate analysis, the association between MAP and rectal descent remained significant (p = 0.01). There was no significant association between BMI and MAP. Conclusions: This cross-sectional study showed an association between MAP and posterior compartment prolapse on imaging as well as between MAP and the bother score of obstructed defecation symptoms. There was no association between BMI and MAP. [ABSTRACT FROM AUTHOR]

Context Dissection of the lateral ligaments during rectopexy has been a source of contention. The purpose of this study was to determine the effect of complete rectal mobilization and lateral ligament division on anorectal functioning after laparoscopic suture rectopexy. Aims Evaluation of anorectal functions in patients with complete and internal rectal prolapse after laparoscopic suture rectopexy with complete division of lateral rectal ligaments. Methods, material, and study design Twenty-five patients with complete and internal rectal prolapse were enrolled in this prospective cohort study between March 2018 and January 2021, including follow-up period. Comparison between pre- and postoperative course included obstructed defecation score, need for laxatives, anorectal manometry pressures, anorectal sensations, and recurrence. Mean follow-up period was 12 months. Statistical analysis Data management and statistical analysis were done using SPSS vs. 25 (IBM, Armonk, NY). Quantitative data were assessed for normality using the Shapiro–Wilk test and direct data visualization methods. Then, quantitative data were summarized as mean and SD or medians and ranges. Categorical data were summarized as numbers and percentages. Longo score and anorectal manometry were compared at different times using repeated-measures analysis of variance. Post hoc analyses were done using the Bonferroni method. Quality of life aspects were compared pre- and postprocedure using paired t-test. McNemar test was used to compare laxative use at different times. All statistical tests were two-sided. P values less than 0.05 were considered significant. Results Preoperatively, 25 patients showed obstructed defecation symptoms. Postoperatively, 23 (92%) patients have significant improvement in Obstructed Defecation Syndrome (ODS) score; however, 40% of them are still depending on laxatives. The remaining two patients (8%) with ODS have no significant improvement in ODS score. Regarding anorectal manometry after surgery, mean squeeze pressure showed significant increase, whereas all rectal sensation showed significant decrease. Patient Assessment of Constipation Quality of Life questionnaire score, total physical discomfort score, total psychosocial discomfort score, and total worries and concerns score were significantly lower postoperatively, whereas the total satisfaction score was significantly higher postoperatively. No recurrences were found. Conclusions Complete mobilization of the rectum during laparoscopic suture rectopexy associated with recovery of anorectal sensation and also improvement in ODS with low recurrence rate reaches 0%. [ABSTRACT FROM AUTHOR]

Background Obstructed-defecation syndrome (ODS) is a condition characterized by the inability to completely evacuate or expel a fecal bolus in the presence of the urge to defecate. A series of mechanical lesions may cause OD, including rectocele, rectoanal intussusception, and rectal prolapse, which may be a cause or an end result of obstruction and chronic straining. The problem with OD, is mainly the difficulty in diagnosis and selection of cases, which could benefit from surgery. Moreover, it is very difficult to determine the suitable surgical technique for each individual case, that is, tailoring of cases. Aim Many surgical techniques have been established either through transanal or laparoscopic approach. Each of these techniques has its benefits and its hazards. Most of the studies in the literature focus on advocating or criticizing a specific surgical technique. This study, however, aims at comparing the results of different surgical techniques through laparoscopic (posterior rectopexy, ventral mesh rectopexy) or transanal (Altemeier's, Delorme's, stapled transanal rectal resection) approach in order to answer a simple question: which approach should be the default and when to use the other?Patients and methods A sample of 28 cases of OD was studied, 14 of which were done through laparoscopic and 14 through transanal approach. Comparison was based on the postoperative hospital stay, complications, and the change in OD score using the 'Altomare ODS questionnaire, 2008.'Results Bleeding was more in laparoscopic techniques, occurring in two (14.3%) of the patients, versus one patient (7.1%) only of those done transanally. Incontinence was more among the transanal group as it occurred in three (21.4%) patients, versus one (7.1%) patient only done laparoscopically. Only one (7.1%) patient done transanally (Delorme's technique), had postoperative anal stenosis requiring anal-dilation sessions. Besides, one (7.1%) of the female patients done through transanal approach, developed rectovaginal fistula. Two of the male patients done by laparoscopic posterior rectopexy developed erectile dysfunction. Laparoscopic techniques had more drop in the ODS score than transanal techniques with a mean of 9.5 ± 6 versus 4.64 ± 5.31, respectively, and a P value of statistical significance (P=0.042). Conclusions Laparoscopic approach is superior to transanal approach as regards improvement of OD manifestations, and thus should be the default, yet the techniques that involve dissection along the posterior rectal wall (posterior mesh rectopexy) are not recommended for males, especially adults. [ABSTRACT FROM AUTHOR]

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Introduction and hypothesis: Symptoms of obstructed defecation (OD) and anatomical abnormalities of the posterior compartment are prevalent in urogynecological patients. The aim of this study was to determine whether perineal hypermobility is an independent predictor of OD, as is the case for rectocele, enterocele and rectal intussusception. Methods: This is a retrospective study of 2447 women attending a tertiary urodynamic center between September 2011 and December 2016. The assessment included a structured interview, urodynamic testing, a clinical examination and 4D transperineal ultrasound. After exclusion of previous pelvic floor surgery and defined anatomical abnormalities of the anorectum, 796 patients were left for analysis. Perineal hypermobility was defined as rectal descent ≥ 15 mm below the symphysis pubis, determined in stored ultrasound volume datasets offline, using proprietary software, blinded to all other data. Any association between perineal hypermobility and symptoms of obstructed defecation was tested for by chi-square (X2) test. Results: For the 796 patients analyzed, median age was 52 (range, 16–88) years with a mean BMI of 27 (range, 15–64) kg/m2. Average vaginal parity was two (range, 0–8). Reported OD symptoms in this group included sensation of incomplete emptying in 335 (42%), straining at stool in 300 (37%) and digitation in 83 (10%). At least one of those symptoms was reported by 424 (53%) women; 153 showed perineal hypermobility. There was no significant association between perineal hypermobility and OD symptoms on univariate testing. Conclusions: We found no evidence of an independent association between perineal hypermobility and obstructed defecation. [ABSTRACT FROM AUTHOR]

ObjectivesThe objective of this study was to describe posterior prolapse (pPOP) and obstructed defecation (OD) symptoms 5 years after open abdominal sacrocolpopexy (ASC).MethodsWe grouped the extended colpopexy and urinary reduction efforts trial participants with baseline and 5-year outcomes into 3 groups using baseline posterior Pelvic Organ Prolapse Quantification (POP-Q) points and concomitant posterior repair (PR) (no PR, Ap

Introduction and hypothesisOptimal measures for assessing anatomy and defecatory symptoms related to posterior compartment prolapse are unknown. Our objectives were: (1) to test the inter- and intrarater reliability of commonly used or reported anatomic measures of posterior compartment prolapse performed in the clinic setting and under anesthesia; and (2) to examine the correlation between posterior compartment anatomy and defecatory symptoms prior to surgical intervention.MethodsA prospective cohort of women with pelvic floor disorders was assessed using a variety of validated questionnaires and standardized examination measures at baseline, at a preoperative visit, and intraoperatively. Inter- and intrarater reliability for anatomic measures were assessed by two separate examiners at the initial visit and repeated by one of the original examiners at a preoperative visit. Reliability was measured using kappa or intraclass correlations according to data type. Symptom and anatomic measure correlations were analyzed using Spearman rank tests.ResultsMean age of the 120 women recruited was 57 ± 15 years, 49 (41 %) had a point Bp ≥ 0; 59 % reported at least moderate bother from at least one obstructed defecation symptom on the Pelvic Floor Distress Inventory (PFDI). At baseline, most anatomic measures showed at least moderate to good inter/intrarater reliability (> 0.5). There were no moderate or better correlations between any symptom and anatomic measure (all r

Abstract Background Growing attention of pelvic floor disorders has led to development of new imaging techniques, with increasing importance of ultrasonography. The 3DUS technique is considered an accessible tool for imaging of the posterior pelvic compartment. The purpose of this study is to highlight the role of 3D ultrasound in evaluation of obstructed defecation in females and comparing the findings with defecography. Results Study included 30 females classified into two groups: (1) 20 patients (case group complaining of obstructed defecation); (2) ten females (control group-normal nulliparous females). All of them were subjected to defecography and 3D ultrasound during resting, squeezing, and straining. Detection rate of rectocele and intussusception with 3D ultrasound was lower than defecography. By US, significant statistical difference between patients and controls in all measurements of levator hiatus, IS, ES, and PRS thickness during straining (P value

Background: 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). Methods: 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. Results: 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). Conclusion: The sampling reflex is impaired in patients with FDD. This finding provides an important insight into the pathogenesis of obstructed functional defecation. [ABSTRACT FROM AUTHOR]

Background: Biofeedback is the most widespread rehabilitative therapy for the treatment of anismus after failed conservative treatment. Osteopathy represents an alternative therapy for constipation. The aim of this study was to evaluate short- and long-term results of osteopathic treatment as compared to biofeedback in patients with dyssynergic defecation. Methods: This was a prospective cohort pilot study on 30 patients with dyssynergic defecation enrolled at the Colorectal Clinic of the University Hospital of Ferrara, Italy, from May 2015 to May 2016 and followed until May 2020. Dyssynergic defecation was defined as the inappropriate contraction of the pelvic floor or less than 20% relaxation of basal resting sphincter pressure (on anal manometry) with adequate propulsive forces during attempted defecation. Dyssynergic patients were divide into 2 treatment groups: 15 patients had osteopathy and 15 patients had biofeedback. Before and 3 months after rehabilitation treatment, all patients had anorectal manometry, defecography, and ultrasound, and were evaluated with the Cleveland Clinic Florida (CCF) constipation score, obstructed defecation syndrome (ODS) score, Colo-rectal-anal Distress Inventory (CRADI-8), Colo-rectal-anal Impact Questionnaire (CRAIQ-7), and the Brusciano Score (BS). To evaluate the efficacy of osteopathy and biofeedback in the long-term, all patients completed the above-mentioned questionnaires 5 years later via a telephone interview. Results: The two treatments were similarly effective in the short term with reduction in questionnaires scores, and increase in the percentage of anal sphincter release at straining at anorectal manometry in both groups. The ODS score was significantly reduced in biofeedback group (p = 0.021). The 3-month post-treatment BS was lower in the osteopathy group, but this just failed to reach statistical significance (p = 0.050). Periodic rehabilitation reinforcements were provided. The CCF constipation score decreased significantly in the osteopathy group (p = 0.023) after 5 years. Conclusions: Osteopathy is a promising treatment for dyssynergic defecation, and it can be associated with biofeedback. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study is to examine the relationship between rectal-vaginal pressure and symptomatic rectocele in patients with pelvic organ prolapse (POP).Method: Patients with posterior vaginal prolapse staged III or IV in accordance with the POP Quantitation classification method who were scheduled for pelvic floor reconstructive surgery in the years 2016-2019 were included in the study. Rectocele was diagnosed using translabial ultrasound, and obstructed defecation (OD) was diagnosed in accordance with the Roma IV diagnostic criteria. Both rectal and vaginal pressure were measured using peritron manometers at maximum Vasalva. To ensure stability, the test was performed three times with each patient.Results: A total of 217 patients were enrolled in this study. True rectocele was diagnosed in 68 patients at a main rectal ampulla depth of 19 mm. Furthermore, 36 patients were diagnosed with OD. Symptomatic rectocele was significantly associated with older age (p < 0.01), a higher OD symptom score (p < 0.001), and a lower grade of apical prolapse (p < 0.001). The rectal-vaginal pressure gradient was higher in patients with symptomatic rectocele (37.4 ± 11.7 cm H2O) compared with patients with asymptomatic rectocele (16.9 ± 8.4 cm H2O, p < 0.001), and patients without rectocele (17.1 ± 9.2 cm H2O, p < 0.001).Conclusion: The rectal-vaginal pressure gradient was found to be a risk factor for symptomatic rectocele in patients with POP. A rectal-vaginal pressure gradient of > 27.5 cm H2O was suggested as the cut-off point of the elevated pressure gradient. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Functional constipation (FC) is a common pediatric healthcare problem worldwide. Obstructed defection syndrome (ODS) is frequently presented with an inability to coordinate the bowel movement with pelvic floor muscles. Botulinum toxin (BT) intraanal sphincteric injection can improve the obstructed defecation by relaxing the anal sphincter and reducing the required force to propel the stools. This study aimed to compare the changes in Rintala scores (as a mean of assessing defecatory function), in children with FC and ODS, managed by BT injection, bowel management program (BMP), and senna based laxatives (SBL), versus a control group managed by BMP and SBL only. Prospective randomized controlled study, started at December 2017 on 40 pediatric patients, divided into 2 equal groups (group A: managed by BMP and SBL, group B: like group A with once intraanal sphincteric BT injection) suffering from FC, ODS, with contrast enema showing persistence of ≤ 90 rectoanal angle (RAA) even with trials of defecation. Patients were excluded if they have neuromuscular abnormalities, hypothyroidism, previous colorectal or anal surgery. Rintala score was assessed before treatment, at 2 months, and 6 months after management. The study included 18 females (45%) and 22 males (55%). Group A had equal gender distribution and mean age of 6.9 years, while group B had 12 males with mean age of 7.35 years. The mean follow up period was 11.35 months in group A and 11.6 months in group B. Mean Rintala scores of both groups at initial presentation, 2 months and 6 months follow up were: group A: 9.10, 9.40, 10.90; group B: 9.30, 10.70, 11.05 respectively, and showed no statistically significant difference (p value: 0.884, 0.294, 0.923 respectively). No complications were detected from BT injection like allergic reactions, neuromuscular urinary or lower limbs disturbances. Intraanal sphincteric injection of botulinum toxin by the mentioned technique and dose, did not result in additional defecatory functional improvement (when assessed by Rintala score) over the routine protocol (using bowel management program and laxatives) of managing functional constipation with obstructed defecation. a preliminary report of this work was presented in the 34th Egyptian pediatric surgery association (EPSA) meeting in Cairo in November 2019. Treatment/prospective study. Level I. [ABSTRACT FROM AUTHOR]

Little is known about the pathophysiological mechanisms of solitary rectal ulcer syndrome (SRUS). We aim to identify the different phenotypes, taking into account complaints, anatomy and anorectal physiology. Complaints, endoscopy results, and physiology data of patients with histologically proven SRUS were collected and analysed. The associated anorectal diseases were faecal incontinence and obstructed defecation. The clinical aspects of SRUS were compared, and factors associated with anorectal diseases were identified. Overall, 102 consecutive patients were included. The predominant lesion was a rectal ulcer (66%), and inflammation of the rectal wall was present in 42% of patients. Abnormal rectal capacities and/or rectal perception was observed in more than half. Nearly half (52%) of the patients met the criteria for obstructed defecation and they tended to more frequently have psychiatric disease (66.7% vs 33.3%; p =0.07). Patients with faecal incontinence (17%) reported more self-perception of anal procidentia (p =0.01) and were more likely to have inflammation of the rectal wall (p =0.02), high-grade internal rectal procidentia (p =0.06) and anal hypotonia (p =0.004); their maximum tolerable volume was lower (p =0.004). The characteristics of patients with SRUS suggest different phenotypes. This may be a way to develop a comprehensive treatment strategy. [ABSTRACT FROM AUTHOR]

Constipation encompasses symptoms of decreased colonic motility or difficulty with the defecation process. As a broad definition, this can be inclusive of functional constipation (FC) or colonic inertia, obstructed defecation (OD), and irritable bowel syndrome-constipation type (IBS-CS). After excluding IBS-C, FC and OD diagnosis and management require a multidisciplinary approach often involving nutritionists, pelvic floor therapists, urogynecologists, and colon and rectal surgeons. Differentiating the presence or absence of each can direct therapy and prognosticate chances for improvement in this often complex combination of disorders., Competing Interests: Disclosure The author has nothing to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The remit of this review is confined to the experimental scientific works and surgeries based on the Integral Theory paradigm. The video abstract summarizes the anorectal function, how ligaments cause dysfunction and cure of fecal incontinence and obstructed defecation by ligament repair. Anorectal function is reflex and binary, with cortical and peripheral components. The same three oppositely acting reflex muscle forces which open and close the bladder, contract against the pubourethral (PUL) and uterosacral (USL) ligaments: (I) to close the anorectum for continence when the puborectalis muscle (PRM) contracts forwards; (II) to open the anorectum prior to evacuation when the PRM relaxes; (III) to stretch the rectum in opposite directions to support the anorectal stretch receptors "N" to prevent premature activation of the defecation reflex, (fecal urgency). Weak or loose PULs or USLs may cause dysfunction of closure, of evacuation, and inability to control the defecation reflex (fecal urgency). Repair of the PUL and USL can improve or cure these dysfunctions. The perineal body (PB) acts as an anatomical support for the distal vagina, anorectum and external anal sphincter (EAS). It serves as an anchoring point for the forward action of the pubococcygeus muscle (PCM), which tensions the anterior rectal wall during closure and defecation. Bladder and bowel dysfunction have a similar pathogenesis, ligament laxity, mainly pubourethral and uterosacral, with added PB damage for anorectal dysfunction. PB damage can cause obstructive defecation and descending perineal syndrome (DPS). Repair of damaged PUL and USL can restore the closure and evacuation functions of both bladder an anorectum. DPS can be cured by repair of the PB's suspensory ligaments, deep transversus perinei., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-23-1883/coif). The series “Integral Theory Paradigm” was commissioned by the International Society for Pelviperineology without any funding or sponsorship. The authors have no other conflicts of interest to declare., (2024 Annals of Translational Medicine. All rights reserved.)

Introduction and hypothesis: The objective was to determine whether levator contraction during Valsalva (i.e. levator co-activation), as visualised on four-dimensional translabial ultrasound (4D-TLUS), is associated with obstructed defecation (OD). Methods: This was a retrospective study including patients attending a tertiary urogynecological unit. All underwent an interview, clinical examination and 4D-TLUS. Frequent straining at stool, digitation or sensation of incomplete emptying during defecation were considered symptoms of OD. Archived 4D-TLUS volumes were evaluated, blinded to all other data. Hiatal anteroposterior (AP) diameter (cm) and hiatal area (cm2) were measured at rest and on maximal Valsalva. Patients with anatomical explanations for OD (rectocele, enterocele and/or rectal intussusception) were excluded. Reduction of hiatal AP diameter and hiatal area on Valsalva were tested for association with symptoms of OD. Results: Overall, 1,383 women attended the unit from May 2013 to July 2016. Seven hundred and eight were excluded because of rectocele (n = 645), enterocele (n = 116) or rectal intussusception (n = 41) and 10 owing to missing data, leaving 665. Mean age was 53 years (16–89), mean body mass index (BMI) 27.3 kg/m2 (15.7–64.4). OD symptoms were reported by 368 (55.3%) patients. On imaging, a reduction in hiatal AP diameter on Valsalva was seen in 11.7% cases (78 out of 665) with a mean reduction of 3.5 mm (0.2–17). A mean reduction in hiatal area of 1.9cm2 (0.03–14.8) on Valsalva was seen in 9.8% cases (65 out of 665). These sonographic measures of levator co-activation were not associated with OD symptoms or bother caused by them (p > 0.05). Conclusions: Levator co-activation seen on TLUS is not associated with obstructed defecation. [ABSTRACT FROM AUTHOR]

Purpose: To assess the subjective and objective outcomes of combined stapled transanal rectal resection (STARR) and urogynecological surgery to treat pelvic organ prolapse, with a 10-year follow-up.Methods: This was a retrospective cohort study analyzing prospectively collected data from 53 consecutive patients who underwent combined stapled transanal rectal resection and urogynecological surgery, from 1 January 2005 to 31 December 2007 at a tertiary referral Pelvic Floor Unit of an Italian hospital.Results: Fifty-three patients with a median age of 60 years (interquartile range (IQR) 67-52t), underwent STARR and concomitant urogynecological surgery. No serious postoperative complications were recorded, and 37/53 women (70%) were evaluated at the 10-year follow-up visit. The cure rate was optimal in 34 women (64.1%). Regarding persistent and/or recurrent symptoms, five sexually-active patients (9%) reported dyspareunia only; obstructed defecation symptoms recurred in ten women (19%); urinary incontinence occurred in eight patients (15%); four patients (11%) reported persistent perineal pain; and two patients (5%) experienced both the urge to defecate and voiding dysfunction. At the 10-year follow-up, 14/27 patients (52%) stated that they would undergo the same operation again, if necessary. Furthermore, the survey found that patients would recommend the combined surgery.Conclusion: The 10-year results of this study proved that combined rectal and urogynecological surgery is well tolerated, associated with low morbidity, and more effectively treats a distressing and debilitating condition vs separate surgeries for rectal and pelvic organ prolapse. We recommend complementing the relatively small scale of this study with randomized trials involving a sufficient number of patients, to provide more conclusive evidence on the cumulative long-term effects of combined surgery vs 2- or 3-stage surgery. [ABSTRACT FROM AUTHOR]

Background: Pelvic organ prolapse (POP) is a dynamic disorder that affects the entire pelvic diaphragm. POP may often involve multiple organs. Abdominal sacrocolpopexy is considered the gold standard to treat female anterior and apical prolapse. Abdominal ventral mesh rectopexy has gained increasing acceptance as an effective treatment for rectal prolapse. The aim of the present study was to assess the safety, feasibility and 1-year outcomes of laparoscopic sacrocolpopexy plus ventral rectopexy as a combined treatment of multicompartment POP. Methods: All female patients at our institution with anterior and apical prolapse with symptoms of obstructed defecation were examined by an urogynecologist and a colorectal surgeon, and were judged suitable for the study. Patients with Pelvic Organ Prolapse Quantification (POP-Q) system stage III and IV and concomitant rectal prolapse were treated by laparoscopic sacrocolpopexy plus ventral rectopexy. After surgery, 1- and 12-month follow-up was performed and the data were retrospectively analyzed. Patients' symptoms were evaluated using the Female Sexual Distress Scale (FSDS), Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12), and Wexner–Agachan constipation score. Results: A total of 98 patients underwent surgery. No intraoperative or postoperative morbidity occurred. At the time of follow-up, all women expressed great satisfaction with the surgical treatment: all the patients had at most POP-Q Stage 1 and 78.8% had a Patient Global Impression of Improvement (PGI-I) score < 3. Significant improvement of symptoms related to POP and to obstructed defecation syndrome, as shown by the FSDS, PISQ-12, and Wexner–Agachan constipation score, was observed in all patients at follow-up Conclusions: Laparoscopic sacrocolpopexy with ventral rectopexy is a feasible and safe procedure for the combined surgical management of anterior, apical, and posterior prolapse, and provides excellent objective and subjective outcomes. [ABSTRACT FROM AUTHOR]

Background: Growing attention of pelvic floor disorders has led to development of new imaging techniques, with increasing importance of ultrasonography. The 3DUS technique is considered an accessible tool for imaging of the posterior pelvic compartment. The purpose of this study is to highlight the role of 3D ultrasound in evaluation of obstructed defecation in females and comparing the findings with defecography. Results: Study included 30 females classified into two groups: (1) 20 patients (case group complaining of obstructed defecation); (2) ten females (control group-normal nulliparous females). All of them were subjected to defecography and 3D ultrasound during resting, squeezing, and straining. Detection rate of rectocele and intussusception with 3D ultrasound was lower than defecography. By US, significant statistical difference between patients and controls in all measurements of levator hiatus, IS, ES, and PRS thickness during straining (P value < 0.001). During straining, cut-off value of 20.75 cm2 for hiatal area gives sensitivity of 100% and specificity of 95% and using ARA, cut-off value of 105° gives sensitivity of 98% and specificity of 90% for differentiation between patients and controls. Conclusion: Ultrasound can be considered a complementary test to defecography in investigation of patients with obstructed defecation. Ultrasound can diagnose levator muscle attenuation and avulsion, thickness of IS, ES, PRS, and distensibility of hiatal area. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Obstructed defecation symptoms (ODS) are common in women; however, the key underlying anatomic factors remain poorly understood. We investigated rectal mobility and support defects in women with and without ODS using pelvic floor ultrasound and MR defecography. Methods: This prospective case-control study categorized subjects based on questions 7, 8 and 14 on the PFDI-20, which asks about obstructed defecation symptoms. All subjects underwent an interview, examination and pelvic floor ultrasound, and a subset of 16 subjects underwent MR defecography. The cul de sac-to-anorectal junction distance at rest and during maximum strain was measured on ultrasound and MRI images. The 'compression ratio' was calculated by dividing the change in rectovaginal septum length by its rest length to quantify rectal folding and hypermobility during dynamic imaging and to correlate with ODS. Results: Sixty-two women were recruited, 32 cases and 30 controls. There were no statistically significant differences in age, parity, BMI or stage of rectocele between groups. A threshold analysis indicated the risk of ODS was 32 times greater (OR 32.5, 95% CI 4.8–217.1, p = 0.0003) among women with a high compression ratio (≥ 14) compared with those with a low compression ratio (< 14) after controlling for age, BMI, parity, stool type and BM frequency. Conclusions: Female ODS are associated with distinct alterations in rectal mobility and support that can be clearly observed on dynamic ultrasound. The defects in rectal support were quantifiable using a compression ratio metric, and these defects strongly predicted the likelihood of symptoms; interestingly, the presence or degree of rectocele defects played no role. These findings may provide new insight into the anatomic factors underlying female ODS. [ABSTRACT FROM AUTHOR]

Objectives: Rectoanal intussusception (RAI) is a common finding on defecography in patients with defecation disorders. This study aimed to compare the proctographic findings and symptoms between patients with anterior RAI and those with circular RAI. Methods: We included 208 patients who were diagnosed as having RAI on defecography. Anorectal function was evaluated using Constipation Scoring System (CSS) and Fecal Incontinence Severity Index (FISI). Results: Twenty-four patients had anterior RAI and 184 had circular RAI. While the anterior intussusception descent or pelvic floor descent was significantly smaller in patients with anterior RAI than those with circular RAI [14.3 vs. 18.5 mm, p=0.004; 12.4 vs. 21.6 mm, p=0.005], there were no significant differences in incidences of obstructed defecation (OD) and fecal incontinence (FI) between the groups. Sixteen patients with anterior RAI and 137 patients with circular RAI had OD. There was no significant difference in the CSS scores between the groups. Twelve patients with anterior RAI and 108 patients with circular RAI had FI. No significant difference in the FISI scores between the groups. Conclusions: Approximately one tenth of the whole RAI was anterior in location, and symptoms in patients with anterior RAI were similar to those with circular RAI.