The role of the defaecating pouchogram in the assessment of evacuation difficulty after restorative proctocolectomy and pouch–anal anastomosis

Stellingwerf, ME; Maeda, Yasuko; Patel, Uday; Vaizey, CJ; Warusavitarne, J; Bemelman, W. A.; Clark, SK

doi:10.1111/codi.13431

Cited by 13 publications

(9 citation statements)

References 16 publications

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“…4 In some patients, 'pouchitis' overlaps with a different class of non-surgical complication that has come to be known as 'pouch dysfunction'. [5][6][7][8] By definition these patients have a pouch that is not working the way it is supposed to work, and the implication is that there is not an obvious cause for the poor function. We have recently written accounts of the physiology of the IPAA.…”

Section: Introductionmentioning

confidence: 99%

When pouches cannot empty: a cohort study of the symptoms this causes, the reasons it's happening, and the treatments needed

Nugent

Church

2022

ANZ Journal of Surgery

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Background Patients with an ileal pouch have a new system of defecation. The expulsive peristalsis of the rectum is replaced by the inertia of the pouch. Defecation becomes dependent on gravity and patients are prone to inefficient pouch‐emptying. Several factors can impact pouch emptying and here we review a series of patients to illustrate these factors and their variable presentations. Methods This is a retrospective, descriptive study of a series of patients who had undergone total proctocolectomy with ileal pouch anal anastomosis and presented with pouch dysfunction. Patients underwent investigations including, pouchoscopy, pouchography and anorectal physiology testing. Results There were 34 patients, 18 men, mean age 48.4 years. Thirty‐one had a J‐pouch and 3 an S‐pouch. Twenty‐eight had a stapled and 6 a hand‐sewn anastomosis. Presenting complaints included difficulty emptying the pouch (n = 17), high stool frequency (n = 8), clinical bowel obstruction (n = 7), and nocturnal incontinence (n = 3). Diagnoses were anal stenosis (11), afferent‐limb syndrome (n = 7), pouch twist (n = 4), paradoxical puborectalis contraction (n = 7), efferent‐limb spasm/stenosis (n = 2), mega‐pouch (n = 3), pouch prolapse (n = 1), and pouch‐rectal anastomosis (n = 1). Treatments included anal dilation (n = 11), disimpaction (n = 2), biofeedback (n = 2), pouch excision (n = 2), laparotomy with lysis of adhesions (n = 6), Botox injection into puborectalis (n = 6), catheter drainage (3), and miralax (n = 11). All patients with a stenosis had some improvement after dilation, and surgery restored pouch function. Conclusions Accurate diagnosis and effective treatment of pouch dysfunction is based on an appreciation of pouch physiology, correction of anatomic abnormalities that impair emptying, and management of stool consistency.

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Section: Introductionmentioning

confidence: 99%

When pouches cannot empty: a cohort study of the symptoms this causes, the reasons it's happening, and the treatments needed

Nugent

Church

2022

ANZ Journal of Surgery

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“…Defaecating pouchography should then be considered if the patient's symptoms do not resolve. Patients with anismus may benefit from biofeedback [79].…”

Section: Causes Of the Pouch Behaving Badlymentioning

confidence: 99%

The pouch behaving badly: management of morbidity after ileal pouch–anal anastomosis

et al. 2021

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Aim Ileal pouch–anal anastomosis (IPAA), or a ‘pouch’, allows restoration of intestinal continuity after proctocolectomy for ulcerative colitis or familial adenomatous polyposis. Most patients have a good long‐term outcome after IPAA, but in a significant proportion the functional outcome and quality of life are unsatisfactory. We term this outcome ‘the pouch behaving badly’. Managing this, especially one is when unfamiliar with the possible underlying pathologies, is a challenge for both patient and clinician. We aim to outline the clinical approach to the pouch behaving badly, highlighting key aspects of investigation and management. Method This is a narrative review of the literature covering the investigation and management of postoperative complications and morbidity after IPAA. Results Management of the pouch behaving badly requires a careful clinical assessment. The patient may present with multiple symptoms and a clear picture of the symptomatology and past history should be constructed before thorough examination and specialist investigation. We divide the pathology that underlies this clinical scenario into surgical, inflammatory, mechanical, functional and dysplastic causes and outline the investigation and management of each one. Conclusion The pouch behaving badly is a challenging problem for both patient and clinician. A detailed clinical assessment with careful specialist investigation is key to diagnosing the underlying pathology. We stress the importance of patient‐centred care – the aim is to improve quality of life.

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“…During anorectal manometry, there is normally an increase in rectal pressure during bearing down, with associated relaxation of the external anal sphincter. This process is under voluntary control, and an inability to perform this coordinated movement is one of the key findings in patients with dyssynergia (36).…”

Section: Anorectal Junction Descent and Rectocele-inmentioning

confidence: 99%

“…pouchocele, pouch prolapse, or dyssynergic defecation. Findings at defecating pouchography have been shown to correlate with clinical symptoms of straining, anal pain, incontinence, and fecal urgency (36). MRI evaluation of ileal pouch-anal anastomosis may provide functional information similar to that of a fluoroscopic defecating pouchogram (37) but can also allow a more complete assessment of the pouch and pelvic anatomy ( Fig 18).…”

Section: Urinary Dysfunctionmentioning

confidence: 99%

MRI of the Male Pelvic Floor

Lakhoo¹,

Khatri²,

Elsayed³

et al. 2019

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The pelvic floor is a complex structure that supports the pelvic organs and provides resting tone and voluntary control of the urethral and anal sphincters. Dysfunction of or injury to the pelvic floor can lead to gastrointestinal, urinary, and sexual dysfunction. The prevalence of pelvic floor disorders is much lower in men than in women, and because of this, the majority of the published literature pertaining to MRI of the pelvic floor is oriented toward evaluation of the female pelvic floor. The male pelvic floor has sex-specific differences in anatomy and pathophysiologic disorders. Despite these differences, static and dynamic MRI features of these disorders, specifically gastrointestinal disorders, are similar in both sexes. MRI and MR defecography can be used to evaluate anorectal disorders related to the pelvic floor. MRI can also be used after prostatectomy to help predict the risk of postsurgical incontinence, to evaluate postsurgical function by using dynamic voiding MR cystourethrography, and subsequently, to assess causes of incontinence treatment failure. Increased tone of the pelvic musculature in men secondary to chronic pain can lead to sexual dysfunction. This article reviews normal male pelvic floor anatomy and how it differs from the female pelvis; MRI techniques for imaging the male pelvis; and urinary, gastrointestinal, and sexual conditions related to abnormalities of pelvic floor structures in men.

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The role of the defaecating pouchogram in the assessment of evacuation difficulty after restorative proctocolectomy and pouch–anal anastomosis

Cited by 13 publications

References 16 publications

When pouches cannot empty: a cohort study of the symptoms this causes, the reasons it's happening, and the treatments needed

When pouches cannot empty: a cohort study of the symptoms this causes, the reasons it's happening, and the treatments needed

The pouch behaving badly: management of morbidity after ileal pouch–anal anastomosis

MRI of the Male Pelvic Floor

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