Fecal Incontinence: Evaluation
Laurence R. Sands, Dana R. Sands in Ambulatory Colorectal Surgery, 2008
Defecography is a dynamic fluoroscopic examination that evaluates anatomical and structural abnormalities of the anorectum and pelvic floor during defecation. Dynamic images can reveal changes in anorectal angle, perineal descent, and anal canal length with rest, squeeze, strain, and evacuation. In addition, defecography assesses the adequacy of rectal emptying and is useful for the diagnosis of rectocele, enterocele, anismus, and megarectum. The anorectal angle should change with defecation (28). The anorectal angle during rest, squeeze, and evacuation has been found to be significantly larger in incontinent patients compared to continent patients (29). Overall, tonic activity of the puborectalis is important for continence and widening of the anorectal angle is associated with weakness of the pelvic floor musculature and anal sphincters. Perineal descent is the caudal movement of the pelvic floor during straining (28). Anal canal length and width is also measured with defecography. Efficiency of rectal emptying can also be measured with > 90% evacuation considered normal. Images may reveal a structural defect such as a rectocele, cystocele, or megarectum, which can result in incomplete evacuation and future soiling (28). For the evaluation of fecal incontinence, defecography is most useful when obstructed defecation is suspected as a cause of the patient’s leakage (30). When mechanical obstruction is not suspected as the cause of fecal incontinence, defecography is generally not recommended as a helpful diagnostic tool.
Fecal incontinence
Miranda A. Farage, Howard I. Maibach in The Vulva, 2017
Defecography is generally reserved as a secondary diagnostic test if the initial studies are inconclusive. It is also user and interpreter dependent, and if not performed at a center that does such procedures routinely, can be misleading. Fluoroscopic defecography is most useful for identifying a rectocele, enterocele (if oral contrast is given), and intussusception/internal rectal prolapse. Contrast material is injected into the rectum, and the patient is then asked to sit and defecate under fluoroscopy. MRI defecography is now being used in some centers as it provides anatomic detail in addition to the functional images. MRI defecography can help identify whether the pelvic floor fails to relax during defecation—also known as anismus. It is important to note that if performed in a traditional MRI machine, the patient likely is defecating supine, which many criticize as not clinically relevant. Open MRI machines allow patients to be evaluated defecating in a sitting position, but costs and availability generally make these prohibitive (12).
Chronic Idiopathic Constipation
Kevin W. Olden in Handbook of Functional Gastrointestinal Disorders, 2020
Defecography is a technique in which barium thickened to a consistency approximating stool is introduced into the rectum (11). Evacuation of the barium can be monitored by fluoroscopy or videotape while the patient sits on a specially constructed commode. Assessment of the anorectal structures, including the anorectal angle, are obtained at rest and during expulsion of the barium mixture. Anatomical abnormalities such as rectoceles and intussusceptions may also be apparent during straining. However, as there is great variability among radiologists with respect to interpreting these studies, more experience with this technique is needed before dicisions can be made with confidence on the basis of radiographic findings.
Chronic refractory constipation due to neurogenic bowel dysfunction can be successfully treated by sacral neurostimulation
Published in Acta Chirurgica Belgica, 2018
Frederiek Nuytens, Mathieu D’Hondt
In September 2015, patient was referred to our department. At that time, patient could pass a small amount of stool every two days with the help of multiple stool softeners (bulk and osmotic), glycerin suppositories and by frequently administering himself enemas. An overview of the medication that was used by the patient to stimulate defecation together with the separate and total cost is listed in Table 1. Patient was also complaining about increasing abdominal discomfort. A defecography showed limited evacuation with the presence of a large residual amount of barium contrast in the rectum. Due to incomplete evacuation of the rectum a subtotal colectomy with ileorectal anastomosis was not a treatment option. A pellet study was found to be positive for slow transit constipation as it showed 47 residual pellets on day 7, diffusely spread over the colon. The Constipation Scoring System (Agachan et al.) showed a total score of 22/30 (Table 2). Finally, a trial with sacral neurostimulation (SNS) was proposed. During ambulatory surgery, a Percutaneous Nerve Evaluation (PNE) was performed. Leads were positioned bilaterally (level S3 both on the right- and the left-hand side) with stimulation of the left-hand side.
Anorectal Function and Quality of Life in IBD Patients With A Perianal Complaint
Published in Journal of Investigative Surgery, 2021
Francesco Litta, Franco Scaldaferri, Angelo Parello, Veronica De Simone, Antonio Gasbarrini, Carlo Ratto
A study by Perera et al. showed that a dyssynergic defecation motor pattern in the ARM was present in almost all patients affected by IBD, despite clinical remission. This common defecation disorder was successfully treated by a subsequent biofeedback therapy [7]. Our study showed that about two-thirds of IBD patients had a dyssynergic defecation motor pattern in ARM, but almost none of them was affected by functional constipation symptoms. Surprisingly, the controls also had a similar dyssynergic pattern rate in the ARM (Table 5). Similar results emerged in a study of 75 patients with functional constipation and 75 healthy controls: 87% of the controls presented a dyssynergic motor pattern in the ARM [25]. Several reasons can explain this apparent paradox, including non-physiologic position during the test (i.e., left lateral position), empty rectum during the examination, embarrassment and anxiety of the patient and of the healthy controls, and ineffective explanation of the maneuvers by the examiner. Therefore, dyssynergic defecation diagnosis requires the following three components: constipation symptom occurrence, manometric or electromyographic evidence of a dyssynergic pattern, plus one other abnormal test as balloon expulsion test or defecography [26].
Elobixibat, the first-in-class Ileal Bile Acid Transporter inhibitor, for the treatment of Chronic Idiopathic Constipation
Published in Expert Opinion on Pharmacotherapy, 2018
For a CIC patient, Idiopathic means that the Health Care Provider cannot identify a reason for the constipation. This clearly differs from the statement that there is no identifiable reason for the constipation. The section on Functional Constipation in Rome III presents a table of identifiable causes of constipation that contains 10 major headings with suggested pathways to the diagnosis and suggested treatment. Although the digital rectal examination (DRE) provides an opportunity to understand the neuromuscular integrity of the pelvic floor, the availability of the thoughtful and expert training necessary to obtain diagnostic DRE expertise is limited. Suggestions for additional diagnostic testing include defecography, full thickness intestinal biopsies, anorectal manometry and intestinal transit studies. Most practicing and academic physicians do not have access to some, or all, of these tests. By default, without the opportunity to confirm a specific diagnosis, the constipation becomes ‘idiopathic’. Many patients in whom a diagnosis could be made with sophisticated studies are being enrolled in CIC clinical trials. The noise created by the patients with causes of constipation outside of the accepted MOA of the investigated drug causes the small therapeutic difference between placebo and an investigated drug in all CIC clinical trials.
Related Knowledge Centers
- Anismus
- Defecation
- Enterocele
- Fluoroscopy
- Rectocele
- Trichuris Trichiura
- Pelvic Floor
- Radiology
- Rectal Prolapse
- Obstructed Defecation