Skip to main content

Advertisement

SpringerLink
Log in

Ultrasonographic patterns in patients with obstructed defaecation

  • Original Article
  • Published:
International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Background

Anal ultrasound is helpful in assessing organic anorectal lesions, but its role in functional disease is still questionable. The purpose of the present study is to assess anal–vaginal–dynamic perineal ultrasonographic findings in patients with obstructed defecation (OD) and healthy controls.

Materials and methods

Ninety-two consecutive patients (77 women; mean age 51 years; range 21–71) with symptoms of OD were retrospectively evaluated. All patients underwent digital exploration, endoanal and endovaginal ultrasound (US) with rotating probe. Forty-one patients underwent dynamic perineal US with linear probe. Anal manometry and defaecography were performed in 73 and 43 patients, respectively. Ultrasonographic findings of 92 patients with symptoms of OD were compared to 22 healthy controls. Anismus was defined on US when the difference in millimetres between the distance of the inner edge of the puborectalis muscle posteriorly and the probe at rest and on straining was less then 5 mm. Sensitivity and specificity were calculated by assuming defaecography as the gold standard for intussusception and rectocele and proctoscopy for rectal internal mucosal prolapse. Since no gold standard for the diagnosis of anismus was available in the literature, the agreement between anal US and all other diagnostic procedures was evaluated.

Results

The incidence of anismus resulted significantly higher (P < 0.05) in OD patients than healthy controls on anal (48 vs 22%), vaginal (44 vs 21%), and dynamic perineal US (53 vs 22%). A significantly higher incidence of rectal internal mucosal prolapse was observed in OD patients when compared to healthy controls on both anal (61.9 vs 13.6%, P < 0.0001) and dynamic perineal US (51.2 vs.9% P = 0.001). For the diagnosis of rectal internal mucosal prolapse, anal US had a 100% sensitivity and specificity. For diagnosis of rectal intussusception, anal US had an 83.3% sensitivity and 100% specificity and perineal US had a 66.6% sensitivity and 100% specificity. In the diagnosis of anismus, anal ultrasonography resulted in agreement with perineal and vaginal US, manometry, defaecography, and digital exam (P < 0.05). Other lesions detected by US in patients with OD include solitary rectal ulcer, rectocele and enterocele. Damage of internal and/or external sphincter was diagnosed at anal US in 19/92 (20%) patients, all continent and with normal manometric values.

Conclusion

Anal, vaginal and dynamic perineal ultrasonography can diagnose or confirm many of the abnormalities seen in patients with OD. The value of the information obtained by this non-invasive test and its role in the diagnostic algorithm of OD is yet to be defined.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Karlbom U, Lundin E, Graf W, Pahlman L (2004) Anorectal physiology in relation to clinical subgroups of patients with severe constipation. Colorectal Dis 6:343–349

    Article  PubMed  CAS  Google Scholar 

  2. Klingele CJ, Bharucha AE, Fletcher JG, Gebhart JB, Riederer SG, Zinsmeister AR (2005) Pelvic organ prolapse in defecatory disorders. Obstet Gynecol 106:315–320

    PubMed  Google Scholar 

  3. Devroede G (1990) Irritable bowel syndrome: intestinal disease or personality disturbance? Gastroenterol Clin Biol 14:3C–4C

    PubMed  CAS  Google Scholar 

  4. Dodi G, Pietroletti R, Milito G, Binda G, Pescatori M (2003) Bleeding, incontinence, pain and constipation after STARR transanal double stapling rectotomy for obstructed defecation. Tech Coloproctol 7:148–153

    Article  PubMed  CAS  Google Scholar 

  5. Roman H, Michot F (2005) Long-term outcomes of transanal rectocele repair. Dis Colon Rectum 48:510–517

    Article  PubMed  Google Scholar 

  6. Wexner SD, Zbar AP, Pescatori M (eds) (2005) Complex anorectal disorders. Springer, Berlin Heidelberg New York

    Google Scholar 

  7. Sultan AH, Loder PB, Bartram CI, Kamm MA, Hudson CN (1994) Vaginal endosonography. New approach to image the undisturbed anal sphincter. Dis Colon Rectum 37:1296–1299

    Article  PubMed  CAS  Google Scholar 

  8. Beer-Gabel M, Teshler M, Barzilai N, Lurie Y, Malnick S, Bass D et al (2002) Dynamic transperineal ultrasound in the diagnosis of pelvic floor disorders: pilot study. Dis Colon Rectum 45:239–248

    Article  PubMed  Google Scholar 

  9. Bouchoucha M, Devroede G, Arsac M (2004) Anismus: a marker of multi-site functional disorders? Int J Colorectal Dis 19:374–379

    Article  PubMed  Google Scholar 

  10. Chen HH, Iroatulam A, Alabaz O, Weiss EG, Nogueras JJ, Wexner SD (2001) Associations of defecography and physiologic findings in male patients with rectocele. Tech Coloproctol 5:157–161

    Article  PubMed  CAS  Google Scholar 

  11. Bartram CI (1992) Anal endosonography. Ann Gastroenterol Hepatol (Paris) 28:185–189

    CAS  Google Scholar 

  12. Rao SS, Mudipalli RS, Stessman M, Zimmerman B (2004) Investigation of the utility of colorectal function tests and Rome II criteria in dyssynergic defecation (Anismus). Neurogastroenterol Motil 16:589–596

    Article  PubMed  CAS  Google Scholar 

  13. Hosie GP, Spitz L (1997) Idiopathic constipation in childhood is associated with thickening of the internal anal sphincter. J Pediatr Surg 32:1041–1044

    Article  PubMed  CAS  Google Scholar 

  14. Fransioli A, Weber B, Cunningham M, Roche B, Marti MC, Hadengue A (1996) Dynamic valuation of puborectalis muscle function by external perineal sonography. Tech Coloproctol 4:125–129

    Google Scholar 

  15. Bouchoucha M, Devroede G, Renard P, Arhan P, Barbier JP, Cugnenc PH (1995) Compartmental analysis of colonic transit reveals abnormalities in constipated patients with normal transit. Clin Sci 89:129–135

    PubMed  CAS  Google Scholar 

  16. Pescatori M, Maria G, Anastasio G, Rinallo L (1989) Anal manometry improves the outcome of surgery for fistula-in-ano. Dis Colon Rectum 32:588–592

    Article  PubMed  CAS  Google Scholar 

  17. Mahieu P, Pringot J, Bodart P (1984) Defecography: II. Contribution to the diagnosis of defecation disorders. Gastrointest Radiol 9:253–261

    Article  PubMed  CAS  Google Scholar 

  18. Halligan S, Bartram CI, Park HJ, Kamm MA (1995) Proctographic features of anismus. Radiology 197:679–682

    PubMed  CAS  Google Scholar 

  19. Park UC, Choi SK, Piccirillo MF, Verzaro R, Wexner SD (1996) Patterns of anismus and the relation to biofeedback therapy. Dis Colon Rectum 39:768–773

    Article  PubMed  CAS  Google Scholar 

  20. Maria G, Sganga G, Civello IM, Brisinda G (2002) Botulinum neurotoxin and other treatments for fissure-in-ano and pelvic floor disorders. Br J Surg 89:1620–1621

    Article  Google Scholar 

  21. Voderholzer WA, Neuhaus DA, Klauser AG, Tzavella K, Muller-Lissner SA, Schindlbeck NE (1997) Paradoxical sphincter contraction is rarely indicative of anismus. Gut 41:258–262

    Article  PubMed  CAS  Google Scholar 

  22. Roche B, Deleaval J, Fransioli A, Marti MC (2001) Comparison of transanal and external perineal ultrasonography. Eur Radiol 11:1165–1170

    Article  PubMed  CAS  Google Scholar 

  23. Pescatori M, Boffi F, Russo A, Zbar AP (2006) Complications and recurrence after excision of rectal internal mucosal prolapse for obstructed defaecation. Int J Colorectal Dis 21:160–165

    Article  PubMed  CAS  Google Scholar 

  24. Solomon MJ, Rex J, Eyers AA, Stewart P, Roberts R (2000) Biofeedback for fecal incontinence using transanal ultrasonography: novel approach. Dis Colon Rectum 43:788–792

    Article  PubMed  CAS  Google Scholar 

  25. Piloni V, Spazzafumo L (2005) Evacuation sonography. Tech Coloproctol 9:119–126

    Article  PubMed  CAS  Google Scholar 

  26. Beer Gabel M, Teshler M, Schechtman E, Zbar AP (2004) Dynamic tranperineal ultrasound vs. defecography in patients with evacuatory difficulty: a pilot study. Int J Colorectal Dis 19:60–67

    Article  PubMed  CAS  Google Scholar 

  27. Nielsen MB, Rasmussen OO, Pedersen JF, Christiansen J (1993) Anal endosonographic findings in patients with obstructed defecation. Acta Radiol 34:35–38

    Article  PubMed  CAS  Google Scholar 

  28. Marshall M, Halligan S, Fotheringham T, Bartram CI, Nicholls RJ (2002) Predictive value of internal anal sphincter thickness for diagnosis of rectal intussusception in patients with solitary rectal ulcer syndrome. Br J Surg 89:1281–1285

    Article  PubMed  CAS  Google Scholar 

  29. Dvorkin LS, Chan CL, Knowles CH, Williams NS, Lunniss PJ, Scott SM (2004) Anal sphincter morphology in patients with full-thickness rectal prolapse. Dis Colon Rectum 47:198–203

    Article  PubMed  Google Scholar 

  30. Cola B, Cuicchi D, Dalla Via B, Lecce F (2005) Endosonographic pattern of solitary polypoid rectal ulcer. Tech Coloproctol 1:71–72

    Google Scholar 

  31. Bollard RC, Gardiner A, Lindow S, Phillips RKS, Duthie GS (2002) Normal female anal sphincter: difficulties in interpretation explained. Dis Colon Rectum 45:171–175

    Article  PubMed  CAS  Google Scholar 

  32. Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI (1993) Anal-sphincter disruption during vaginal delivery. N Engl J Med 329:1905–1911

    Article  PubMed  CAS  Google Scholar 

  33. Tjandra JJ, Lim JF, Hiscock R, Rajendra P (2004) Injectable silicone biomaterial for fecal incontinence caused by internal anal sphincter dysfunction is effective. Dis Colon Rectum 47:2138–2146

    Article  PubMed  CAS  Google Scholar 

  34. Senagore A, Gallagher T, Hull T, Ferrara A (2005) A shor-term assessment of the efficacy of the STARR procedure for obstructed defecation syndrome. Dis Colon Rectum 48:634

    Article  Google Scholar 

  35. Halligan S, Bartram CI, Hall C, Wingate DJ (1996) Enterocele revealed by simultaneous evacuation proctografy and peritoneography: does “defecation blok” exist? Am J Roentgenol 167:461–466

    CAS  Google Scholar 

  36. Lienemann A, Anthuber CJ, Baron A, Reiser M (1996) Dynamic MR colpocystorectography. A new methods for evaluating pelvic floor descent and genital prolapse. Aktuelle Radiol 6:182–186

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. First Division of General and Gastrointestinal Surgery, School of Medicine, Second University of Naples, Naples, Italy

    L. Brusciano, P. Limongelli, V. Napolitano, V. Maffettone, G. Rossetti, G. del Genio, G. Russo, F. Pizza & A. del Genio

  2. Coloproctology Unit, Villa Flaminia Hospital, Rome, Italy

    M. Pescatori & G. Gagliardi

Authors
  1. L. Brusciano
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. P. Limongelli
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. M. Pescatori
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. V. Napolitano
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. G. Gagliardi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. V. Maffettone
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. G. Rossetti
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. G. del Genio
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. G. Russo
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. F. Pizza
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. A. del Genio
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to L. Brusciano.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Brusciano, L., Limongelli, P., Pescatori, M. et al. Ultrasonographic patterns in patients with obstructed defaecation. Int J Colorectal Dis 22, 969–977 (2007). https://doi.org/10.1007/s00384-006-0250-2

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00384-006-0250-2

Keywords

Search

Navigation