MR defecography detects pelvic floor dysfunction in participants with chronic complete spinal cord injury.

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

MR defecography in patients with dyssynergic defecation: spectrum of imaging findings and diagnostic value.

OBJECTIVES: We describe the spectrum of findings and the diagnostic value of MR defecography in patients referred with suspicion of dyssynergic defecation. METHODS: 48 patients (34 females, 14 males; mean age 48 years) with constipation and clinically suspected dyssynergic defecation underwent MR defecography. Patients were divided into patients with dyssynergic defecation (n = 18) and constipated patients without dyssynergic defecation (control group, n = 30). MRIs were analysed for evacuation ability, time to initiate evacuation, time of evacuation, changes in the anorectal angle (ARA-change), presence of paradoxical sphincter contraction and presence of additional pelvic floor abnormalities. Sensitivity, specificity, positive and negative predictive values and accuracy for the diagnosis of dyssynergic defecation were calculated. RESULTS: The most frequent finding was impaired evacuation, which was seen in 100% of patients with dyssynergic defecation and in 83% of the control group, yielding a sensitivity for MR defecography for the diagnosis of dyssynergic defecation of 100% (95% confidence interval (CI) 97-100%), but a specificity of only 23% (95% CI 7-40%). A lower sensitivity (50%; 95% CI 24-76%) and a high specificity (97%; 95% CI 89-100%) were seen with abnormal ARA-change. The sensitivity of paradoxical sphincter contraction was relatively high (83%; 95% CI 63-100%). A combined analysis of abnormal ARA-change and paradoxical sphincter contraction allowed for the detection of 94% (95% CI 81-100%) of the patients with dyssynergic defecation. CONCLUSION: MR defecography detects functional and structural abnormal findings in patients with clinically suspected dyssynergic defecation. Impaired evacuation is seen in patients with functional constipation owing to other pelvic floor abnormalities than dyssynergic defecation.

Prediction of findings at defecography in patients with genital prolapse.

OBJECTIVE: Defecography may be useful in pre-operative assessment of patients with genital prolapse. Defecography is an invasive and embarrassing procedure for patients and little effort has been made to optimalise selection criteria for defecography. This study investigated whether discrimination of high and low probability of abnormal defecography is possible based on the quantified findings from patient history, pelvic examination and a validated questionnaire. DESIGN: Prospective observational study. SETTING: Three teaching hospitals in The Netherlands. POPULATION: Eighty-two patients undergoing surgical correction of uterine prolapse Stages 2-4. METHODS: A history and pelvic examination were obtained from all patients. A validated questionnaire was used to assess the presence of defecation and micturition symptoms. Using multivariate logistic regression analyses with receiver operating characteristic curves, a diagnostic model to predict the presence of an abnormal defecography was systematically constructed and validated. MAIN OUTCOME MEASURE: Presence of abnormal finding at defecography. RESULTS: The most important predictors for abnormal defecography were prolapse of the posterior vaginal wall, history of abdominal or pelvic surgery and the presence of constipation. With these variables, a prediction rule could be constructed which predicted the prevalence of an abnormal defecography (area under curve = 0.73; 95% CI 0.61-0.83). CONCLUSIONS: This study shows that a diagnostic model based on findings obtained from a non-invasive workup can accurately predict the presence of an abnormal defecography. Such a model provides the possibility to tailor the request for defecography to the individual patient.

Defecography in patients with anorectal disorders: a study in 27 cases.

Defecography of twenty-seven cases of anorectal disorders with an age range from 22 to 86 years, were evaluated from June 1989 to February 1999. There were 24 patients with constipation, 2 patients with incomplete defecation and mucous bloody stool in one case. The defecographic results were analyzed regarding the following 1) anorectal angle, defined both at rest and straining 2) abnormalities of the rectal configuration during straining, including rectocele, intussusception, infolding and ulceration. 3) pelvic floor descent. The results showed abnormal anorectal angle 5 cases, rectocele 15 cases, intussusception of the rectal wall 3 cases, infolding 11 cases, ulceration 7 cases and anal canal constriction 1 case. Consequently, the patients with anorectal disorders were found to have a variety of rectal abnormalities in which the defecography would be the imaging tool in demonstrating them.

[Diagnostic value of defecography]. / Valor diagnóstico de la defecografía.

The aim of this study was to assess the importance of defecatography in the diagnosis of lower chronic constipation (4) or rectal type (12), principally in those patients on whom other diagnostic methods had not produced supportive data. Over a 64 month period, 65 patients who had consulted because of chronic constipation, were studied; they were suffering from low bowel symptoms like difficulty in the evacuation of the rectum. The average age was 48 and mostly female. All of them were asked to prepare the same mixture for the defecatory study, using the same type of contrast material and study technique. In most of the cases correlated functional elements were found, while very few cases resulting from just organic causes were found, and only one without functional or organic reason was found. Our results were as follows. 1) Insufficient laxity of the pubo-rectal beam related to forward or backward rectocele or lowering of the increased pelvic floor, a fact that was found in 19 patients (29.23%). 2) Inadequate laxity of the pubo rectal beam in 12 patients (18.46%). 3) Paradoxical contraction of the pubo rectal beam related to forward rectocele or lowering of the increased pelvic floor, in 11 patients (16.92%). 4) Lowering of the increased pelvic floor, related to forward or backward rectocele in 8 patients (12.30%). 5) Paradoxical contraction of the pubo rectal beam in 7 patients (10.76%). 6) Forward or backward rectocele in 3 patients (4.61%). 7) Lowering of the increased pelvic floor in 2 patients (3.07%). 8) Rectal intususception in 1 patient (1.53%). 9) Average study in 1 patient (1.53%). Therefore, the defecatography is a very useful method of study to appraise constipation with anorectoperineal symptoms, as it allows us to diagnose organic and functional problems in the area (6). Likewise, the importance of pre and post surgical tests, both therapeutic and reconstructive must be underlined.

Intraobserver and interobserver measurements of the anorectal angle and perineal descent in defecography.

PURPOSE: Anorectal angle and perineal descent can be measured either by drawing a line defined by the impression of the puborectalis muscle and the tangential of the posterior rectal wall (Method A) or by drawing a straight line at the level of the posterior rectal wall parallel to the central longitudinal axis of the rectum (Method B). The aim of this study was to assess the reproducibility of measuring anorectal angle and perineal descent by two different methods according to intraobserver and interobserver measurement and to evaluate which method yields more consistent results. METHODS: Five physicians who have had an average of 1.3 years (range, 6 months to 1.5 years) experience in defecographic measurement drew both lines on 63 randomly selected defecographic films and measured anorectal angle and perineal descent by the two methods. The defecographic parameters were measured twice by each observer during a three-week interval. To avoid potential bias, one physician who did not participate in either measurement of perineal descent or anorectal angle performed all data collection. Intraobserver and interobserver agreement was quantified using Shrout and Fleiss intraclass correlation coefficients. RESULTS: The mean and range of intraclass correlation coefficients for intraobserver agreement of measuring anorectal angle and perineal descent by Method A were 0.71 (0.6-0.78) and 0.89 (0.74-0.97), respectively, whereas with Method B the coefficients were 0.81 (0.73-0.89) and 0.93 (0.89-0.99), respectively. Regarding the interobserver agreement of the five observers, the mean coefficients for measurement of both anorectal angle and perineal descent by both methods showed similar agreement levels (0.88 and 0.98 by Method A and 0.89 and 0.97 by Method B). The mean (+/- standard deviation) values of anorectal angle and perineal descent found by Method B were significantly larger than those found by Method A (103.3 degrees +/- 19.6 and 6.56+/-3.20 cm and 91.1 degrees +/- 25.6 and 5.64+/-3.42 cm, respectively; P<0.001). CONCLUSION: Intraobserver and interobserver intraclass correlation coefficients of anorectal angle and perineal descent, which were measured by both methods, were more than 0.60, indicating that both methods are reliable and consistent for measurement of anorectal angle and perineal descent. However, centers should consistently use the same line for measurement of anorectal angle and perineal descent because of the statistically significant differences between the two methods and the possibility of inconsistent results.