Videodefaecography Combined with Measurement of the Anorectal Angle and of Perineal Descent

Abstract

Cineradiographic defaecography combined with measurement of the anorectal angle and descent of the pelvic floor is proposed. The method used in 73 women gave valuable information in 48 patients who complained of anal incompetence, rectal tenesmus, and chronic constipation. In these patients, high and low rectal intussusception, rectocele, and pathologic movement of the pelvic floor were detected. Some of these phenomena could only be diagnosed by the radiologic method here described. Quantitations of the anorectal angle and descent of the pelvic floor placed the group with constipation halfway between normal individuals and those with anal incompetence. The value of this finding is discussed. Recent improvements in anorectal surgery often make videodefaecography decisive for the choice of the optimal operative method. Therefore, videodefaecography together with measurement of the anorectal angle and pelvic floor descent is recommended whenever anorectal surgery for correction of functional disturbances is contemplated.Since the pioneer work of BRODEN & SNELLMAN in 1968 (4), cinedefaecography has only been sporadically mentioned in the literature (1, 5-7). However, during the past few years, anal incompetence has become a less concealed complaint in the female population. The fact that more patients demand help, and the refinement of therapeutic options, make cinedefaecography an important method to reveal abnormalities in the pelvic floor. Dysfunction in the anorectal region of psychologic origin cannot always be excluded (10, II).Since methods for objective diagnostic procedures are indicated, to improve cinedefaecography, we combined real-time videotape recordings with quantitative measurements of the anorectal angle (ARA) and descent of the pelvic floor (D). Material and MethodsVideodefaecography was performed in 73 women with a mean age of 55 years (range 26-82, evenly distributed). Twenty-five women were asymptomatic volunteers with a mean age of 53 years (range 28-78). Of the other 48 women, 25 had anal incompetence, 2 had flatus incompetence, 2 rectal tenesmus, 15 chronic constipation, and 4 patients had different complaints and were examined twice.The patients were prepared in the same way as for barium examination of the colon. Approximately 200 ml of thick barium contrast medium (a mixture of half-volume Mixobar oesophagus and half-volume Mixobar suspension) was instilled through a catheter into the rectum. At the end of instillation, the catheter was carefully withdrawn in order to mark the anal canal with contrast medium. The patient was then placed in a standardized pot chair in front of a fluoroscopic unit, with the lateral view of the rectum positioned in the centre of the field. Fluoroscopy was registered on videotape during rest and evacuation. The fluoroscopic position was held static during the whole procedure. Both the rectum, the anal canal, and the upper edge of the pot chair had to be visible on the TV simultaneously.From the video sequence, static images were acquired during rest and under...

Physiology and Pathophysiology of Anal Function

“…As a group, these patients show decreased anal resting and squeeze pressures (13), decreased anorectal pressure gradients (29), increased anorectal angle and perineal descent (27), increased pudendal nerve terminal motor latencies, increased muscle fibre density by single fibre electromyography and decreased activity of the anal sphincter muscles by standard electromyography (1 1).…”

Sex differences in anorectal angle and perineal descent

“…The male pelvis is less "crowded," thus allowing for bigger individual variations in the position of the rectum. The value of ARA and D measurements is already limited in female patients, although there are significant differences between patients with and without symptoms [1,6]. The results in the male patients presented here show that ARA measurements are even less applicable in men to a preoperative evaluation of corrective surgery, but 2 features are worth mentioning.…”

“…First, the ARA is generally bigger in male than in female patients, indicating a more vertical placement of the rectum. If this sexrelated difference is neglected, the ARA values in the majority of men will equal those measured in women with anal incompetence [6]. Second, the spread of normal ARA values is close to twice as great in men as in women, indicating greatly reduced clinical applicability.…”

“…D is similar in the 2 groups. However, use of D alone has limited value, except in patients with a very large D [6].…”

Constipation Assessed on the Basis of Colorectal Physiology

“…Cinedefecography is a dynamic study of anorectal function, first described by Ekengren & Snellman (15) and later modified by others (16)(17)(18). This investigation was performed in the radiology department, where the patient was first given 150 ml barium orally to facilitate the recognition of smallbowel loops.…”