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Abstract

Pelvic floor disorders such as obstructed defecation and faecal incontinence are common, and frequently underreported in the UK population. Defined as excessive straining, a feeling of blocked evacuation and the need for perineal support or digitation to initiate evacuation, obstructed defecation affects 10–20% of women. 1,2 Obstructed defecation can be associated with a spectrum of clinical findings including rectocoele, enterocoele, intussusception, rectal prolapse ³ and anismus.
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a!=D=;7!DH!1/%!T>'E=8D99;8?'E!S'?'!E'9=!
D>=Q!S8=K!$$1!?'EPD9E'E!?':'8G'L!H?DJ!




89!;!L8E=?8:=!B'9'?;7!KDEP8=;7!E'==89B.
Expertise and training

E=;='L!=K;=!=K'C!K;L!;!EP':8;7!89='?'E=!



HD?!H>?=K'?!J;9;B'J'9=.!,9!=KDE'!SKD!
?'EPD9L'LQ!=K'!P?8J;?C!L'E=89;=8D9!
HD?!P;=8'9=E!?'H'??'L!D9S;?LE!S;E!=D!;!


U'89B!?'H'??'L!=D!;!:D7D?':=;7!9>?E'!
EP':8;78E=!HD?!;EE'EEJ'9=0=?';=J'9=.
a77!E>?B'D9E!SKD!L8L!9D=!K;G'!;!EP':8;78E=!

7'EE!=K;9!"1R!DH!=K'8?!=8J'!=?';=89B!=K'E'!


L8ED?L'?E!EP'9=!JD?'!=K;9!1#R!DH!=K'8?!




=8J'!D9!=?';=89B!P;=8'9=E!S8=K!P'7G8:!

+H!=K'!E>?B'D9E!SKD!K;L!;!EP':8;78E=!






9D=!K;G'!;!EP':8;78E=!89='?'E=!;9L!L8L!9D=!

>9L'?BD9'!;!HD?J;7!P'?8DL!DH!=?;8989B!89!





;77!K;L!:;??8'L!D>=!;9!;==;:KJ'9=!=D!;!



DH!=?;8989B!U'=S''9!=KDE'!>9L'?BD89B!
;!H'77DSEK8P!;9L!=KDE'!>9L'?BD89B!;9!




:7898:!:D9E8E=89B!DH!:D7D?':=;7!E>?B'D9E!



 
  +UE=?>:='L!L'H':;=8D9!
E:D?'

67'G'7;9L!67898:!E:D?'  ACJP=DJ!E'G'?8=C!E:D?' 
W'X9'?!E:D?'   
cD:ZSDDL!E:D?'  cDJ'!,,!:?8='?8; 
+=K'?  *8L!9D=!;9ES'? 
FAd!+b!O++<A !b+c!aAAdAAYdNO!+b!6+NO,NdN6d!aN*!+IAOcF6Od*!

%07)'$E
 0FF8::$G?$;?G= 
*'H':;=8D9!
P?D:=DB?;PKC
  
a9;7!J;9DJ'=?C   
d9LD;9;7!
>7=?;ED9DB?;PKC
  
Y;B9'=8:!?'ED9;9:'!
P?D:=DB?;PKC
  

JD=D?!7;='9:C
  
d7':=?DJCDB?;PKC   
a9;7!'7':=?8:;7!
E=8J>7;=8D9
  
c':=;7!U;77DD9!
'XP>7E8D9!='E=
  
c':=;7!J;X8J;7!
=D7'?;U7'!GD7>J'
  
 

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'"
THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BULLETIN
J''=89B0VD89=!:7898:!U'=S''9!=';:K89B!;9L!


Clinical assessment


S;E!=K'!W'X9'?!E:D?'!S8=K!/$03#!





>E89B!=K'!'7':=?D98:!P'?ED9;7!;EE'EEJ'9=!
_

E=?>:=>?'L!K8E=D?C.
,9!=K'!:7898:;7!;EE'EEJ'9=!DH!P;=8'9=E!
P?'E'9=89B!S8=K!=K'!ECJP=DJE!DH!
DUE=?>:='L!L'H':;=8D9Q!=K'!J;VD?8=C!DH!

?':=;7!;9L!G;B89;7!'X;J89;=8D9!=D!;EE'EE!


>E89B!G;B89;7!'X;J89;=8D9!D97C.!WK'9!
'X;J8989B!P;=8'9=EQ!=K'!J;VD?8=C!DH!
?'EPD9L'9=E!>E'L!;!E>UV':=8G'!B?;L89B!

89!=K'!;EE'EEJ'9=!DH!=K'!;9;=DJ8:;7!




89!B?;L89B!=K'!E8e'!DH!89=>EE>E:'P=8D9!




ECE='J!89!B?;L89B!?':=D:D'7'!E8e'.
,9!='?JE!DH!=K'!=DD7E!>E'L!=D!E:D?'!=K'!
H>9:=8D9;7!E'G'?8=C!DH!:D9E=8P;=8D9!;9L!
DUE=?>:='L!L'H':;=8D9Q!/$0%5!?'EPD9L'9=E!



cDJ'!,,!:?8='?8;!HD?!:D9E=8P;=8D9!;9L!50%5!
_
Investigation tools

L8ED?L'?EQ!;!S8L'!?;9B'!DH!JDL;78=8'E!

+G'?!)4R!DH!?'EPD9L'9=E!>E'L!EDJ'!

>E89B!L'H':;=8D9!P?D:=DB?;PKC!;9L!

P?D:=DB?;PKC.!+97C!"504)!?'EPD9L'9=E!


a!G;?8'=C!DH!D=K'?!=':K98T>'E!S'?'!>E'L!
7'EE!H?'T>'9=7C!89:7>L89B!P>L'9L;7!9'?G'!



;9L!?':=;7!J;X8J;7!=D7'?;U7'!GD7>J'!

K;L!=D!?'H'?!'X='?9;77C!=D!:;??C!D>=!
=K'E'!89G'E=8B;=8D9E.
Treatment options
,9!='?JE!DH!=K'!P?D:'L>?'E!HD?!
89:D9=89'9:'!P'?HD?J'L!UC!=K'!
?'EPD9L'9=EQ!=K'!JDE=!H?'T>'9=7C!;G;87;U7'!
P?D:'L>?'!S;E!=K'!;9='?8D?!EPK89:='?!





D=K'?!DP=8D9E!S'?'!;7ED!;G;87;U7'!=D!;!

89:7>L89B!P'?:>=;9'D>E!=8U8;7!9'?G'!
E=8J>7;=8D9Q!=K'!Y;7D9'!;9='B?;L'!

E=?8:=7C!EP';Z89B!9D=!;!P?D:'L>?'!HD?!


E=;='L!=K;=!;7=KD>BK!=K'C!:D>7L!P'?HD?J!
=K'E'!P?D:'L>?'EQ!=K'?'!S;E!9D!H>9L89B!
;G;87;U7'!=D!:;??C!=K'J!D>=.
bD?!E>?B8:;7!:D??':=8D9!DH!DUE=?>:='L!
L'H':;=8D9Q!=K'!JDE=!PDP>7;?!P?D:'L>?'!
HD?!=K'!=?';=J'9=!DH!89=>EE>E:'P=8D9!
S;E!E= ;P7'L!=?;9E;9;7!?':=;7!?'E':=8D9!




bD?!:D??':=8D9!DH!?':=D:D'7'Q!=K'!
JDE=!PDP>7;?!J'=KDL!DH!?'P;8?!S;E!



   
 

D>=!DP'9!=?;9E;ULDJ89;7!?'P;8?!
DH!?':=D:D'7'.



?'EPD9E'!?;='!?'P?'E'9='L!D97C!"#R!DH!
F\!:D7D?':=;7!E>?B'D9E.!OCP8:;7!?'EPD9E'!
?;='E!HD?!DUE'?G;=8D9;7!E=>L8'E!J;87'L!=D!
PKCE8:8;9E!;?'!1#(3#R."3!OK8E!L8E:?'P;9:C!
J;C!U'!U':;>E'!S'!:;??8'L!D>=!;9!

?'EPD9E'!?;='Q!D?!U':;>E'!?'EPD9L'9=E!
D97C!?'P78'L!8H!=K'C!H'7=!=K'C!K;L!;9C!

7DS!?'EPD9E'!?;='E!:D>7L!7';L!=D!U8;E!;E!

P?DU;U7C!JD?'!78Z'7C!=D!?'EPD9L!=D!=K8E!
T>'E=8D99;8?'!=K;9!E>?B'D9E!SKD!L8L!9D=!

a!S8L'EP?';L!G;?8;=8D9!89!P?;:=8:'Q!
;::'EE!=D!89G'E=8B;=8D9E!;9L!G;?8;U878=C!89!



L8ED?L'?E!LD!9D=!;PP';?!=D!K;G'!
?';ED9;U7'!=DD7E!HD?!=K'!89G'E=8B;=8D9!DH!
E>:K!L8ED?L'?E.!OK'!7;:Z!DH!E=;9L;?L8E;=8D9!
;9L!B>8L'789'E!J;C!8JP;:=!D9!P;=8'9=!
D>=:DJ'E!HD?!=K'!J;9;B'J'9=!DH!
=K'E'!L8ED?L'?E.
OK8E!:D>7L!U'!L>'!=D!=K'!7;:Z!DH!;G;87;U878=C!
DH!HD?J;7!=?;8989B.!a7=KD>BK!;!?':'9=!
PK'9DJ'9D9Q!D97C!3.4R!DH!?'EPD9L'9=E!

H'77DSEK8PQ!S8=K!=K'!?'J;89L'?!?':'8G89B!

H'77DSEK8PE!'X8E=!89!=K'!F\!U>=!=K'E'!='9L!
=D!U'!?'E=?8:='L!=D!:D7D?':=;7!E>?B8:;7!
P?;:=8:'!;9L!;PP';?!=D!K;G'!78J8='L!D?!
9D!89='?;:=8D9!S8=K!>?DBC9;':D7DBC.!W'!
?':DJJ'9L!=K;=!;!JDG'!=DS;?LE!P'7G8:!


:DJP'='9:8'E!;9L!=8J'!P'?8DLE!HD?!
E>?B'D9E!=;Z89B!D9!=K'E'!H'77DSEK8PE.!OK8E!
 
@?;L'!,(,f  
AJ;770JDL'?;='07;?B'  


 
+=K'?  
*8L!9D=!;9ES'?  

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THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BULLETIN
=?;8989B!P'?8DL!:D>7L!;7ED!;77DS!=?;8989B!89!
89G'E=8B;=8D9;7!JDL;78=8'E!E>:K!;E!'9LD;9;7!
>7=?;ED9DB?;PKC!;9L!;9D?':=;7!PKCE8D7DBC.!
,9='?'E=89B7CQ!=KDE'!?'EPD9L'9=E!SKD!K;L!



OK'!E':D9L!?';ED9!HD?!7;:Z!DH!
E=;9L;?L8E;=8D9!89!=K'!J;9;B'J'9=!DH!

D9BD89B!L'U;='!;UD>=!=K'!E>8=;U878=C!DH!
G;?8D>E!E>?B8:;7!=':K98T>'E!HD?!?'P;8?!DH!
=K'E'!L8ED?L'?E.!a9!'X;JP7'!DH!=K8E!8E!=K'!
L'U;='!E>??D>9L89B!=K'!>E'!DH!=?;9E;9;7!

:D??':=8D9!DH!?':=D:D'7'."4!*'EP8='!
K;G89B!BDDL!D>=:DJ'E!89!J>7=8P7'!=?8;7EQ!
:D9=?DG'?EC!E=877!'X8E=E!?'B;?L89B!8=E!

G'9=?;7!J'EK!?':=DP'XC!;9L!PDE='?8D?!

S8=K!D=K'?!P?D:'L>?'EQ!;7=KD>BK!B>8L;9:'!
H?DJ!=K'!N;=8D9;7!,9E=8=>='!HD?!M';7=K!
;9L!6;?'!dX:'77'9:'!'9LD?E'E!8=E!?D>=89'!
>E'!HD?!=K'!=?';=J'9=!DH!DUE=?>:='L!
L'H':;=8D9.")!OK'?'!8E!;9!DUG8D>E!9''L!HD?!

=?8;7E!:DJP;?89B!=':K98T>'E!S8=K!';:K!
D=K'?!?;=K'?!=K;9!89!8ED7;=8D9!=D!'E=;U78EK!
E>P'?8D?8=C!HD?!9;=8D9;7!B>8L'789'E.
W8=K!?'EP':=!=D!9;=8D9;7!B>8L'789'EQ!
=K'?'!8E!;!P;>:8=C!DH!89HD?J;=8D9!;9L!
B>8L;9:'!?'B;?L89B!=K'!L8;B9DE8E!;9L!

Y;9C!=':K98T>'E!'X8E=!HD?!L8;B9DE8EQ!




E>BB'E=!=K;=Q!;=!;!J898J>JQ!:D9E'9E>E!
B>8L'789'E!U'!HD?J>7;='L!HD?!=K'!

=K'!F\!U;E'L!D9!'G8L'9:'!DU=;89'L!H?DJ!
?;9LDJ8E'L!:D9=?D77'L!=?8;7E!DH!:DJJD97C!
>E'L!=':K98T>'E.
OK'?'!8E!;7ED!;!7;:Z!DH!E=;9L;?L8E;=8D9!
;9L!;G;87;U878=C!DH!89G'E=8B;=8D9;7!=DD7E!

>9L'?!5#R!DH!?'EPD9L'9=E!>E'L!EDJ'!
HD?J!DH!P?D:=DB?;PKC!HD?!L8;B9DE8E!;9L!
V>E=!>9L'?!1#R!K;L!;::'EE!=D!'9LD;9;7!
>7=?;ED9DB?;PKC!D?!;9D?':=;7!PKCE8D7DBC.!

'??D?.!MDS'G'?Q!8H!:D??':=Q!8=!7';LE!=D!
=K'!:D9:7>E8D9!=K;=!;::'EE!=D!=K'E'!
89G'E=8B;=8D9E!9''LE!=D!U'!'9K;9:'L!
=D!P?DG8L'!;!U'=='?!T>;78=C!DH!:;?'!=D!
P;=8'9=E.!a7ED!DH!9D='!8E!=K'!>E'!DH!
;?U8=?;?C!E>UV':=8G'!;EE'EEJ'9=!ECE='JE!
HD?!B?;L89B!=K'!E8e'!DH!?':=D:D'7'E!;9L!
89=>EE>E:'P=8D9Q!S8=K!=K'!J;VD?8=C!DH!

ECE='J!?;=K'?!=K;9!;!DUV':=8G'!ECE='J!
"5!D?!+XHD?L!?':=;7!
P?D7;PE'!B?;L'./#!a!L':8E8D9!?'B;?L89B!=K'!
E=;9L;?L8E;=8D9!DH!'X;J89;=8D9!=':K98T>'!
9''LE!=D!U'!J;L'!=D!;77DS!:DJP;?8ED9!

U'=S''9!L8HH'?'9=!:7898:8;9E!;9L!:'9=?'E.
,=!8E!'9:D>?;B89B!=D!9D='!=K;=!JD?'!
=K;9!1#R!DH!?'EPD9L'9=E!>E'!EDJ'!

>E'!DH!Y*O!J''=89BE!K;E!'XP;9L'L!=D!
J;9C!L8E:8P789'EQ!K;G89B!U''9!:;??8'L!
D>=!HD?!=K'!P;E=!$1!C';?E!89!:D7D?':=;7!
:;9:'?.!dG8L'9:'!'X8E=E!=K;=!=K'C!
8JP?DG'!D>=:DJ'E!89!?':=;7!:;9:'?Q/$!;9L!


8JP?DG'!D>=:DJ'E!HD?!P;=8'9=E!;9L!EKD>7L!
U':DJ'!P;?=!DH!?D>=89'!:;?'.
YD?'!:D9=?DG'?E8;7!8E!=K'!?'7;=8D9EK8P!
U'=S''9!GD7>J'!DH!E>?B'?C!P'?HD?J'L!
;9L!D>=:DJ'E.!OK'?'!8E!9D!89HD?J;=8D9!

U>=!=K8E!K;E!U':DJ'!;!=DP8:!DH!L'U;='!
89!:D7D?':=;7!:;9:'?!E>?B'?CQ/"!S8=K!;!
:7';?!?'7;=8D9EK8P!EKDS9!U'=S''9!U'=='?!
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THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BULLETIN
Mayday Pelvic Floor Questionnaire
This questionnaire is anonymous. Please mark your answers with a cross.
Please return in the attached stamped addressed envelope. Many thanks for your time.
Q1. Do you have a special interest in pelvic floor Yes No
dysfunction?
If you answered yes to Q1, go to Q4.
If you answered no to Q1, go to Q2.
Q2. If not, do you refer to another clinician? Yes No
If you answered yes to Q2, go to Q3.
If you answered no to Q2, you have finished.
Q3. Who do you refer to? Colorectal surgeon
with pelvic floor interest
Continence nurse
specialist
Other: __________________
Q4. What percentage of your practice is concerned >75%
with pelvic floor disorders?
5075%
2550%
<25%
Q5. Have you had formal training in the management Yes No
of pelvic floor disorders?
If you answered yes to Q5, go to Q6.
If you answered no to Q5, go to Q7.
Q6. How were you trained in the management of Pelvic floor fellowship
pelvic floor disorders?
Attachment to pelvic floor unit
(Duration: ____ months)
Q7. Do you have: Pelvic floor multidisciplinary
team
Combined pelvic floor clinic
0(('45+M$H
'3
THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BULLETIN
Q8. What tools do you use for assessing continence? FIQL scale
Cleveland Clinic score
Wexner score
Rockwood score
Other: __________________
Q9. What surgical treatment for anal incontinence can you Anterior sphincter repair
personally perform for patients? (Tick all that apply.)
Injectable bulking agent
Sacral nerve stimulator
Artificial sphincter
Gracilloplasty
Other: __________________
Q10. In patients presenting with obstructed defecation,Rectal exam
how do you typically perform an examination?
Vaginal exam
Rectal and vaginal exam
None
Q11. How would you grade the size of a rectocoele?Grade IIV
IV =
III =
II =
I =
Small/moderate/large
Pelvic organ prolapse
quantification
Other: __________________
Q12. How would you grade the size of an intussusception?Grade I–V
V =
IV =
III =
II =
I =
Small/moderate/large
'4
THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BULLETIN
Pelvic organ prolapse
quantification
Other: __________________
Q13. How would you treat intussusception surgically? Anterior rectopexy
Posterior rectopexy
Anterior resection
Stapled transanal rectal
resection
Q14. How would you treat rectocoele surgically? Transanal
Transvaginal
Transperineal
Transabdominal (laparoscopic)
Transabdominal (open)
Q15. To which of the following modalities do you have access
andwhich of those do you actually use?
Refer externally Access in unit Use
a) Defecation proctography
b) Anal manometry
c) Endoanal ultrasonography
d) Magnetic resonance proctography
e) Pudendal nerve motor latency
f) Electromyography
g) Anal electrical stimulation
h) Rectal balloon expulsion test
i) Rectal maximal tolerable volume
Q16. In which year did you qualify? __________
')
Article
Background: Obstructed defaecation syndrome (ODS) is difficulty in evacuating stools, requiring straining efforts at defaecation, having the sensation of incomplete evacuation, or the need to manually assist defaecation. This is due to a physical blockage of the faecal stream during defaecation attempts, caused by rectocele, enterocele, intussusception, anismus or pelvic floor descent. Evacuation proctography (EP) is the most common imaging technique for diagnosis of posterior pelvic floor disorders. It has been regarded as the reference standard because of extensive experience, although it has been proven not to have perfect accuracy. Moreover, EP is invasive, embarrassing and uses ionising radiation. Alternative imaging techniques addressing these issues have been developed and assessed for their accuracy. Because of varying results, leading to a lack of consensus, a systematic review and meta-analysis of the literature are required. Objectives: To determine the diagnostic test accuracy of EP, dynamic magnetic resonance imaging (MRI) and pelvic floor ultrasound for the detection of posterior pelvic floor disorders in women with ODS, using latent class analysis in the absence of a reference standard, and to assess whether MRI or ultrasound could replace EP. The secondary objective was to investigate differences in diagnostic test accuracy in relation to the use of rectal contrast, evacuation phase, patient position and cut-off values, which could influence test outcome. Search methods: We ran an electronic search on 18 December 2019 in the Cochrane Library, MEDLINE, Embase, SCI, CINAHL and CPCI. Reference list, Google scholar. We also searched WHO ICTRP and clinicaltrials.gov for eligible articles. Two review authors conducted title and abstract screening and full-text assessment, resolving disagreements with a third review author. Selection criteria: Diagnostic test accuracy and cohort studies were eligible for inclusion if they evaluated the test accuracy of EP, and MRI or pelvic floor ultrasound, or both, for the detection of posterior pelvic floor disorders in women with ODS. We excluded case-control studies. If studies partially met the inclusion criteria, we contacted the authors for additional information. Data collection and analysis: Two review authors performed data extraction, including study characteristics, 'Risk-of-bias' assessment, sources of heterogeneity and test accuracy results. We excluded studies if test accuracy data could not be retrieved despite all efforts. We performed meta-analysis using Bayesian hierarchical latent class analysis. For the index test to qualify as a replacement test for EP, both sensitivity and specificity should be similar or higher than the historic reference standard (EP), and for a triage test either specificity or sensitivity should be similar or higher. We conducted heterogeneity analysis assessing the effect of different test conditions on test accuracy. We ran sensitivity analyses by excluding studies with high risk of bias, with concerns about applicability, or those published before 2010. We assessed the overall quality of evidence (QoE) according to GRADE. Main results: Thirty-nine studies covering 2483 participants were included into the meta-analyses. We produced pooled estimates of sensitivity and specificity for all index tests for each target condition. Findings of the sensitivity analyses were consistent with the main analysis. Sensitivity of EP for diagnosis of rectocele was 98% (credible interval (CrI)94%-99%), enterocele 91%(CrI 83%-97%), intussusception 89%(CrI 79%-96%) and pelvic floor descent 98%(CrI 93%-100%); specificity for enterocele was 96%(CrI 93%-99%), intussusception 92%(CrI 86%-97%) and anismus 97%(CrI 94%-99%), all with high QoE. Moderate to low QoE showed a sensitivity for anismus of 80%(CrI 63%-94%), and specificity for rectocele of 78%(CrI 63%-90%) and pelvic floor descent 83%(CrI 59%-96%). Specificity of MRI for diagnosis of rectocele was 90% (CrI 79%-97%), enterocele 99% (CrI 96%-100%) and intussusception 97% (CrI 88%-100%), meeting the criteria for a triage test with high QoE. MRI did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of MRI performed with evacuation phase was higher than without for rectocele (94%, CrI 87%-98%) versus 65%, CrI 52% to 89%, and enterocele (87%, CrI 74%-95% versus 62%, CrI 51%-88%), and sensitivity of MRI without evacuation phase was significantly lower than EP. Specificity of transperineal ultrasound (TPUS) for diagnosis of rectocele was 89% (CrI 81%-96%), enterocele 98% (CrI 95%-100%) and intussusception 96% (CrI 91%-99%); sensitivity for anismus was 92% (CrI 72%-98%), meeting the criteria for a triage test with high QoE. TPUS did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of TPUS performed with rectal contrast was not significantly higher than without for rectocele(92%, CrI 69%-99% versus 81%, CrI 58%-95%), enterocele (90%, CrI 71%-99% versus 67%, CrI 51%-90%) and intussusception (90%, CrI 69%-98% versus 61%, CrI 51%-86%), and was lower than EP. Specificity of endovaginal ultrasound (EVUS) for diagnosis of rectocele was 76% (CrI 54%-93%), enterocele 97% (CrI 80%-99%) and intussusception 93% (CrI 72%-99%); sensitivity for anismus was 84% (CrI 59%-96%), meeting the criteria for a triage test with very low to moderate QoE. EVUS did not meet the criteria to replace EP. Specificity of dynamic anal endosonography (DAE) for diagnosis of rectocele was 88% (CrI 62%-99%), enterocele 97% (CrI 75%-100%) and intussusception 93% (CrI 65%-99%), meeting the criteria for a triage test with very low to moderate QoE. DAE did not meet the criteria to replace EP. Echodefaecography (EDF) had a sensitivity of 89% (CrI 65%-98%) and specificity of 92% (CrI 72%-99%) for intussusception, meeting the criteria to replace EP but with very low QoE. Specificity of EDF for diagnosis of rectocele was 89% (CrI 60%-99%) and for enterocele 97% (CrI 87%-100%); sensitivity for anismus was 87% (CrI 72%-96%), meeting the criteria for a triage test with low to very low QoE. Authors' conclusions: In a population of women with symptoms of ODS, none of the imaging techniques met the criteria to replace EP. MRI and TPUS met the criteria of a triage test, as a positive test confirms diagnosis of rectocele, enterocele and intussusception, and a negative test rules out diagnosis of anismus. An evacuation phase increased sensitivity of MRI. Rectal contrast did not increase sensitivity of TPUS. QoE of EVUS, DAE and EDF was too low to draw conclusions. More well-designed studies are required to define their role in the diagnostic pathway of ODS.
Article
Full-text available
O B J E C T I V E S To determine the diagnostic accuracy of MRI, ultrasound and EP (reference standard), for the detection of posterior compartment disorders in patients with ODS, with a view to make recommendations regarding the ideal investigation for ODS. Secondary objectives 1 To estimate test accuracy for each test at pre-specified thresholds 2 To investigate sources of heterogeneity (subgroup analysis)
Article
Full-text available
To evaluate the effect of multidisciplinary team (MDT) treatment modality on outcomes of patients with gastrointestinal malignancy in China. Data about patients with gastric and colorectal cancer treated in our center during the past 10 years were collected and divided into two parts. Part 1 consisted of the data collected from 516 consecutive complicated cases discussed at MDT meetings in Peking University School of Oncology (PKUSO) from December 2005 to July 2009. Part 2 consisted of the data collected from 263 consecutive cases of resectable locally advanced rectal cancer from January 2001 to January 2005. These 263 patients were divided into neoadjuvant therapy (NT) group and control group. Patients in NT group received MDT treatment, namely neoadjuvant therapy + surgery + postoperative adjuvant therapy. Patients in control group underwent direct surgery + postoperative adjuvant therapy. The outcomes in two groups were compared. The treatment strategy was altered after discussed at MDT meeting in 76.81% of gastric cancer patients and in 58.33% of colorectal cancer patients before operation. The sphincter-preservation and local control of tumor were better in NT group than in control group. The 5-year overall survival rate was also higher in NT group than in control group (77.23% vs 69.75%, P = 0.049). MDT treatment modality can significantly improve the outcomes of patients with gastrointestinal malignancy in China.
Article
Purpose: Constipation is a common complaint; however, clinical presentation varies with each individual. The aim of this study was to assess a standard scoring system for evaluation of constipated patients. Materials and methods: All consecutive patients with idiopathic constipation who were referred for anorectal physiologic testing were assessed. A subjective constipation score was calculated based on a detailed questionnaire that included over 100 constipation-related symptoms. Based on the questionnaire, scores ranged from 0 to 30, with 0 indicating normal and 30 indicating severe constipation. The constipation score was then compared with the objective findings of the physiology tests, which include colonic transit time (CTT), anal manometry (AM), cinedefecography (CD), and electromyography (EMG). Colonic inertia was defined as diffuse marker delay on CTT without evidence of paradoxical contraction on AM, CD, or EMG. Pelvic outlet obstruction was defined as paradoxical puborectalis contraction, rectal prolapse or rectoanal intussusception, rectocele, or sigmoidocele. Results: A total of 232 patients (185 females and 47 males) of a mean age of 64.9 (range, 14-92) years were evaluated. All patients had a score of more than 15; on evaluation of the significance of different symptoms in the constipation score with the Pearson's linear correlation test, 8 of 18 factors were identified as significant (P < 0.05). These factors included frequency of bowel movements, painful evacuation, incomplete evacuation, abdominal pain, length of time per attempt, assistance for evacuation, unsuccessful attempts for evacuation per 24 hours, and duration of constipation. All 232 patients had objective obstruction attributable to one or more of the following causes: paradoxical puborectalis contraction (81), significant rectocele or sigmoidocele (48), rectoanal intussusception (64), and rectal prolapse (9). Conclusion: The proposed constipation scoring system correlated well with objective physiologic findings in constipated patients to allow uniformity in assessment of the severity of constipation.
Article
Pelvic floor dysfunction (PFD) is a type of functional constipation. The effectiveness of biofeedback as a treatment remains unclear. A systematic review of all randomized controlled trials evaluating the effectiveness of biofeedback in adults with PFD was carried out. All online databases from 1950 to 2007 were searched. This was supplemented by hand searching references of retrieved articles. Seven trials fulfilled the inclusion criteria. Three compared biofeedback with non-biofeedback treatments and four compared different biofeedback modalities. Electromyography feedback was most widely utilized. The trials were heterogeneous with varied inclusion criteria, treatment protocols and definitions of success. Most had methodological limitations. Quality of life and psychological morbidity were assessed rarely. Meta-analysis of the studies involving any form of biofeedback compared with any other treatment suggested that biofeedback conferred a sixfold increase in the odds of treatment success (odds ratio 5.861 (95 per cent confidence interval 2.175 to 15.794); random-effects model). Although biofeedback is the recommended treatment for PFD, high-quality evidence of effectiveness is lacking. Meta-analysis of the available evidence suggests that biofeedback is the best option, but well designed trials that take into account quality of life and psychological morbidity are needed.
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Stapled transanal rectum resection is becoming increasingly popular as a surgical option for the treatment of obstructive defecation syndrome. However, details about the anatomical changes produced by stapled transanal rectum resection and its correlation with success or failure is poorly understood. The aim of this study was to correlate the defecographical and clinical patterns in patients treated with stapled transanal rectum resection. Based on a multi-institutional stapled transanal rectum resection registry composed of a total of 182 patients, correlation analysis of clinical and radiological parameters was prospectively obtained from 51 patients with a completed 12-month follow-up. Postoperative defecography shows significant changes in the following parameters: intussusception (89%-19%; P < .0001), enterocele (38%-18%; P = .038), rectocele (mean ± SD: 27.1 ± 7.4 mm to 16.5 ± 9.7 mm; P < .0001), rectal lumen (mean ± SD: 46 ± 11.4 mm to 35 ± 9.9 mm; P < .0001), anorectal angle (mean ± SD: 146.4 ± 10.6° to 132.4 ± 11.1°; P = .002), pelvic floor descent (mean ± SD: 59 ± 18 mm to 47 ± 1.3 mm; P = .0001), and, as a dynamic parameter, dynamic pelvic floor descent (mean ± SD: 30 ± 0.8 mm to 17 ± 0.4 mm; P < .0001). Of these parameters, reduction of intussusception (r = 0.433, 95% CI 0.15-0.61; P = .003), rectocele (r = 0.507, 95% CI 0.26-0.67; P = .001), and dynamic pelvic floor descent (r = 0.427, 95% CI 0.31-0.64; P = .001) correlated with a significant improvement in constipation. Reduction of intussusception positively affected postoperative continence (r = 0.524, 95% CI 0.29-0.70; P = .001), whereas reduced rectal lumen size correlated with incontinence and fecal urgency (r = -0.557, 95% CI -0.69 to -0.28; P = .001). Improved constipation after stapled transanal rectum resection is associated with improvement of intussusception, rectocele, and dynamic pelvic floor descent. Postoperative continence is determined by 2 parameters, reduction of intussusception and rectal lumen size, which have opposing effects. Reduction of rectal lumen size may be responsible for new-onset fecal urgency, which is occasionally seen after stapled transanal rectum resection.
Article
The purpose of this study was to assess the usefulness of the defecation phase during dynamic MR defecography. The images from 85 MR defecographic examinations (83 patients; age range, 20-88 years; mean, 52.7) were retrospectively reviewed in consensus by two observers. Images from each of four phases (rest, maximal sphincter contraction and squeezing, maximal straining, and defecation) were evaluated and scored independently with a modified previously published grading system. Features evaluated included the presence and degree of bladder, vaginal, and rectal descent and the presence and size of rectocele, enterocele, and intussusception. Statistical analysis was performed with a variety of tests. Compared with images obtained in the other phases, defecation phase images helped in identification of additional cases of abnormal bladder descent in 43 examinations (50.6%), abnormal vaginal descent in 52 examinations (61.2%), and abnormal rectal descent in 11 examinations (12.9%). Similarly, only defecation phase images depicted previously undetected rectoceles 2 cm or larger in 31 examinations (36.5%), enteroceles in 34 examinations (40%), and intussusceptions in 22 examinations (25.9%). The number of additional cases of abnormalities identified on defecation phase images was significantly greater than the number identified on images obtained in the other phases (p < 0.005). The average total scores for the rest, squeeze, strain, and defecation phases were 1.4, 0.7, 2.3, and 6.6. The average total defecation phase score was significantly greater than the average total score in any of the other phases (p < 0.001). During dynamic MR defecography, defecation phase imaging yields important additional information on the presence and degree of pelvic floor abnormalities and is therefore an essential component of MR defecographic examinations.
Article
#### Summary points Rectal prolapse is an extrusion of the full thickness of the wall of the rectum beyond the anal verge. Internal rectal prolapse, or intussusception, is defined as a full thickness prolapse of the rectum that does not protrude through the anus. Rectal prolapse and intussusception often coexist with a rectocoele (herniation of the rectovaginal septum anteriorly into the vagina) and an enterocoele (deep herniation of the rectovaginal peritoneum). Globally, these problems are often referred to as “pelvic floor dysfunction,” and this review focuses on the posterior compartment, the rectum, around which these pathologies occur. Patients with these conditions are often unable to empty the rectum effectively (obstructed defecation syndrome) and make up about half of the estimated 2-27% of the population with constipation; the remainder have a problem of colonic inertia.1 They may also get additional symptoms including faecal incontinence and pain. Interest in rectal prolapse has recently increased, with a multicentre randomised trial (PROSPER) now completed comparing surgical techniques. The advent of laparoscopic surgery also offers a potentially less invasive, better tolerated, and more durable surgical solution. Initial surgical attempts at treating intussusception were disappointing and led to its virtual abandonment for many years in favour of conservative measures. However, in recent years, good results with acceptable morbidity have been reported for perineal and laparoscopic/abdominal approaches, so that patients with substantial symptoms should be referred for consideration for surgery. We review evidence from epidemiological studies, observation …
Article
Chronic constipation affects almost one in six adults and is even more frequent in the elderly. In the vast majority of patients, there is no obstructive mucosal or structural cause for constipation and, after excluding relatively rare systemic diseases (commonest of which is hypothyroidism), the differential diagnosis is quickly narrowed down to three processes: evacuation disorder of the spastic (pelvic floor dyssynergia, anismus) or flaccid (descending perineum syndrome) varieties, and normal or slow transit constipation. Treatment of chronic constipation based on identifying the underlying pathophysiology is generally successful with targeted therapy. The aims of this review are to discuss targeted therapy for chronic constipation: behavioural treatment for outlet dysfunction and pharmacological treatment for constipation not associated with outlet dysfunction. In particular, we shall review the evidence that behavioural treatment works for evacuation disorders, describe the new treatment options for constipation not associated with evacuation disorder, and demonstrate how 'targeting therapy' to the underlying diagnosis results in a balanced approach to patients with these common disorders.