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Chapter 3.1(ii) Defecography: A Swedish Perspective*

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Chapter 3.1(ii)

Defecography: A Swedish Perspective*

Annika López, Jan Zetterström, and Anders F. Mellgren

Introduction

The dynamics of rectal evacuation may be displayed by defecography (evacuation proctography). The technique has gained importance as an investigatory tool in patients with anorectal disorders, and the method has been evaluated in a series of studies. During recent years, variants of the technique have been described, opening up the possibility to investigate patients with other pelvic floor symptoms primarily located in other pelvic compartments.

Historical Background

The first publications using cineradiographic techniques for studying the mechanism of defecation were published in the 1960s (1–3). However, the technique was not widely spread until the work of Mahieu et al. (4,5) and Ekberg et al. (6), who increased the global interest in defecography.

Defecography is useful in studying anorectal functional and detecting anatomic abnormalities as possible causes of defecation disturbances.

Rectocele, enterocele, rectal intussusception, and rectal prolapse can be visualized, and several authors have found defecography useful as a com- plement to the clinical examination (7,8). Kelvin et al. (9) reported that

“evacuation proctography” has a useful role in enterocele detection prior to surgery for pelvic prolapse.

Hock et al. (10) introduced colpo-cysto-defecography of the female pelvis, and Altringer et al. (11) described “four-contrast defecography” with contrast medium in the small bowel, rectum, vagina, and urinary bladder, finding the method helpful in the planning of prolapse surgery. Adminis- tration of contrast medium intraperitoneally has been used to study normal

*Ed note: This chapter should be read in conjunction with Chapter 3.1(i)

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anatomy and in the evaluation of patients with obscure symptoms in the groin or pelvis (12). The use of intraperitoneal contrast medium in combi- nation with defecography is advocated by some authors (13,14). With this technique, the peritoneal outline is directly visualized and a deep pouch of Douglas can be demonstrated for enhanced diagnosis of peritoneocele and enterocele.

Indications

The most common indication for defecography is constipation presenting as difficult or infrequent evacuation. This issue is extensively discussed in the sections of Chapter 6. Some authors have stressed the role of defecog- raphy in incontinent patients with intact sphincters. Defecography may then diagnose a rectal intussusception or identify patients with an obtuse anorec- tal angle suitable for post-anal repair, as well as patients with large recto- celes who present with a combination of evacuatory dysfunction and incontinence.

A clinical examination, including rectal palpation and rigid proctoscopy or flexible sigmoidoscopy, should be performed before defecography. In several patients, a full colonoscopy also is indicated. A gynecological exam- ination is recommended in female patients. Defecography may be useful in patients with symptoms such as pelvic heaviness or discomfort due to a vaginal protrusion. It is important to assess the pelvic floor as one unit because several symptoms may be present and combinations of anatomical weaknesses are common (15).

Technical Aspects

The techniques of defecography are by no means standardized. Contrast filling of the rectum is universal and contrast medium in the vagina is used by a majority of institutions. Opacification of the small bowel is used only by a few (16), and bowel preparation prior to the investigation is preferred by some (17), but not by others (18–20).

If contrast in the small bowel is used, it is administered orally one to two hours prior to the investigation. Oral contrast is recommended to enable detection of an enterocele, especially when no contrast medium is instilled intraperitoneally (2,4–6). Rectal contrast media of varying consistencies are used and both regular barium enema contrast medium and thick barium paste are employed. Some mix the contrast medium with potato starch, potato flakes, or cellulose to achieve a consistency similar to that of feces.

The contrast medium usually is injected with a pistol injector with the patient in the left lateral position. The injected amount varies; some inves- tigators instill contrast medium until a strong urge to defecate is provoked,

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whereas others use the same volume in all cases. Sometimes liquid contrast is administered prior to the paste to opacify the sigmoid colon in order to detect a sigmoidocele.

Contrast medium in the vagina enhances the possibilities for studying enterocele and rectocele. A contrast medium gel or a tampon soaked with contrast medium is used. The use of a gel is preferable, as a tampon might obscure important diagnostic information (21). Some authors place gauze at the introitus to avoid leakage of contrast medium from the vagina in order to improve the image (22).

After instillation of contrast medium, the patient is seated on a plastic commode in front of a fluoroscopic unit, and the investigation usually is performed in the lateral view. The patient is asked to strain and empty the rectum. As the investigation is rapid and dynamic, it is documented best with video. Spot films sometimes are added to the investigation; these films usually are taken at key points of the study (e.g., at the start, during straining, and after completion of “defecation”). At some centers, an anterior–posterior spot film is added to reveal the coronal configuration of the rectum to help diagnose intussusception (23) and to lateralize a pro- lapsed organ (15). To minimize the dose exposure, imaging should be inter- mittent if rectal evacuation is prolonged. Newer digital systems allow substantial reduction in dose.

The procedure usually is not painful for the patient, but it can be stress- ful, and therefore it is important to explain the procedure thoroughly to the patient beforehand and provide maximal privacy and reassurance for the patient during the procedure.

Radiographic Analysis

Although defecography is a well-established method, there are no standard definitions of the radiographic findings. Studies with asymptomatic volun- teers have revealed a range of normal values, and some overlap with patho- logical states (24). Therefore, it is important to evaluate the findings at defecography in relation to the patients’ symptoms, clinical findings, and other functional tests because the anatomical changes found may not always be the cause of the patient’s problems.

Rectal Emptying and the Anal Canal

Rectal emptying can be studied by defecography. At the start, before strain- ing is initiated, there should be no leakage of contrast medium. Constipated patients often empty the rectum slowly and incompletely. An emptying time of more than 30 seconds is considered pathological. The anal canal should open during emptying of the rectum, close after emptying, and remain closed at rest.

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Rectal Intussusception and Rectal Prolapse

A rectal intussusception starts six to eleven centimeters above the anal verge by formation of a circular indentation, which progressively deepens.

Its apex descends towards the anal verge on straining. It sometimes is dif- ficult to differentiate between rectal intussusception and “normal” mucosal folds of the rectum at straining. The size of the intussusception can be graded in different ways, but a commonly used system has the following three grades. When the intussusception remains within the rectum, it is called recto-rectal; when the apex penetrates the anal canal, it is referred to as recto-anal; and an external rectal intussusception that protrudes through the anal verge is equivalent to a rectal prolapse (Figures 3.1(ii).1 and 3.1(ii).2).

Mucosal Prolapse

Defecography usually can differentiate between a mucosal prolapse and a full-thickness rectal prolapse. However, sometimes the differentiation can be difficult, even on defecography. According to Ekberg et al. (6), mucosal

Figure 3.1(ii).1. A 56-year-old woman previously operated for a lumbar disc her- niation with persistent minor loss of sensitivity in her legs. The patient suffers from anal incontinence and rectal emptying difficulty with excessive straining and a need for digital assistance by pressing on the perineum during defecation. Defecography with contrast medium in the rectum, vagina, and small bowel was performed and the examination demonstrates a rectal intussusception reaching down into the anal canal during straining. V, vagina; R, rectum; Ri, rectal intussusception; arrow, the base of the intussusception.

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prolapse starts three to four centimeters above the anal verge containing only the mucosa [see Figure 3.1(ii).5(b)] (25).

Enterocele

In females, an enterocele usually is diagnosed as a bowel-filled peritoneal sac located between the posterior vaginal wall and the anterior rectal wall, descending below the upper third of the vagina. It often contains small bowel, but sigmoid colon is sometimes evident. In males, it is diagnosed as bowel within a rectal intussusception or a rectal prolapse (Figure 3.1(ii).3).

Rectocele

A rectocele is seen at defecography as a bulge outside the projected line of the anterior rectal wall during straining. The size of the rectocele is measured as the distance between the extended line of the anterior border of the anal canal and the tip of the rectocele (Figure 3.1(ii).4).

Figure 3.1(ii).2. A 44-year-old woman with a two-year history of a rectal prolapse.

Defecography was performed with contrast medium in the rectum, vagina. and small bowel and demonstrates a rectal prolapse during straining. V, vagina; R, rectum;

RP, rectal prolapse; SB, Small bowel.

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Figure 3.1(ii).3. A 66-year-old woman previously operated on with hysterectomy after which there were worsening symptoms of constipation with infrequent bowel emptying about two times a week. Defecography was performed with contrast medium in the rectum, vagina, and small bowel and demonstrates a rectal intus- susception reaching into the anal canal and a large enterocele during straining.

V, vagina; R, rectum; arrows, rectal intussusception; Ec, enterocele.

Figure 3.1(ii).4. A 52-year-old woman with a life-long history of constipation, straining, and a sensation of incomplete rectal evacuation. Defecography was per- formed with contrast medium in the rectum, vagina, and small bowel and demon- strates a rectocele during straining. V, vagina; Rc, rectocele; SB, small bowel; arrows, normal mucosal folds.

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Perineal Descent

The level of the pelvic floor is estimated on defecography by measuring the distance between the anorectal junction (ARJ) and a fixed structure, such as the ischial tuberosity, the coccyx, or the pubococcygeal line (a line drawn from the lower point of the pubic symphysis and the coccyx). In general, it is accepted that defecography provides the most accurate estimate of per- ineal descent. However, it is defined in different ways by different authors.

Excessive perineal descent can be defined at the start of the examination as a resting anorectal junction positioned more than three centimeters below the ischial tuberosity. It also can be defined as anorectal junction descent of more than three and a half centimeters during maximal strain- ing (26) (Figure 3.1(ii).5).

The Anorectal Angle

The anorectal angle (ARA) can be studied on straining, after the comple- tion of defecation, during squeezing, and at rest (Figure 3.1(ii).6). It can be determined either by estimating a straight line along the posterior border of the rectum or by using the central longitudinal axis (the areas above and below the axis are equal) of the lower rectum and the anal canal (Figure 3.1(ii).6). The range of values for the ARA in asymptomatic subjects is quite wide, but the mean values are rather consistent (27). The ARA is normally wider during straining than at rest due to the relaxation of the puborectalis muscle. Signs of paradoxical sphincter reaction (anismus, paradoxical pelvic floor contraction) can be seen at defecography as an increased impression of the puborectalis muscle or as a reduction of the ARA at straining.

Measurement of the ARA or ARJ descent appears to be of little clinical value (28), but it assists in providing some validation of new techniques such as dynamic transperineal sonography [see Chapter 3.2(ii)] (29).

Rectovaginal Space

The space between the contrast medium in the vagina and the contrast medium in the rectum. The width of the rectovaginal space is normally less than one centimeter in the middle portion and assists in the diagnosis of peritoneocele.

Interpretation

After studying 56 asymptomatic patients, Mahieu et al. (4) described a normal defecogram in which several conditions were almost always present.

An increase in ARA at the beginning of defecation is seen due to an

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Figure 3.1(ii).5. A 40-year-old man with constipation and excessive straining at stool. During the last year the patient noticed a prolapse with spontaneous reposi- tioning after defecation. Defecography was performed with contrast medium in the rectum and small bowel. (a) Defecography at rest. The anorectal junction is above the ischial tuberosities. (b) Defecography during straining. An extreme case of per- ineal descent is seen with the anorectal junction significantly below the ischial tuberosities. A mucosal prolapse also is seen. R, rectum; IT, ischial tuberosities;

arrow, anorectal junction; arrowhead, mucosal prolapse.

a

b

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increase in intra-abdominal pressure. The increase in ARA is a consequence of the relaxation of the puborectalis sling, whose impression obliterates the posterior wall of the distal part of the rectal ampulla at rest. The anal canal opens widely to permit passage of rectal content until evacuation is com- plete, without excessive straining. The pelvic floor shows good resistance, not allowing an excessive descent.

Even though there is an overlap between normal values and pathologic states, there is a broad agreement with the description by Mahieu et al. (4) regarding these normal findings. Concerning the anorectal angle, subse- quent studies have shown considerable interobserver variation in estimat- ing the ARA (30); this reflects the degree of difficulty in this interpretation.

The correlation between measurement of the ARA and clinical symptoms has been poor, and therefore its clinical value is controversial.

On defecography, a paradoxical sphincter reaction (anismus, paradoxical pelvic floor contraction) is suspected when the puborectalis impression is increased and the ARA is decreased during straining (see Chapter 6.4).

Most authorities, however, prefer to study this phenomenon with electromyography (EMG), whereas some authors recommend a combina- tion of EMG, defecography, and manometry (31–33). The clinical signifi- cance of paradoxical sphincter reaction (PSR) in constipated patients is debated, as PSR also may be found in nonconstipated patients (34).

However, several reports have demonstrated success in treating patients with PSR using biofeedback (35).

Figure 3.1(ii).6. A 45-year-old woman. Defecography with contrast medium in the rectum, vagina, and small bowel was performed and is normal. The anorectal angle (ARA) is indicated at rest, estimating a straight line along the posterior border of the rectum and the anal canal. V, vagina; R, rectum; SB, small bowel; arrow, ARA.

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Both rectal intussusception and mucosal prolapse also may be found in asymptomatic subjects (20,24). In some studies where the rectal intussus- ception was corrected surgically, the symptoms of constipation persisted, suggesting that intussusception is a secondary phenomenon (36,37).

However, in patients with rectal prolapse and solitary rectal ulcer syndrome (SRUS), surgical intervention may be successful (38).

Rectocele is a frequent finding in patients with defecation disorders.

However, rectoceles are common in women because the rectovaginal septum is relatively weak, and a minor bulge of the anterior rectal and pos- terior vaginal wall are likely to be a normal variant. At defecography, a rec- tocele usually is not seen at rest, but is visualized during straining. The size can be estimated and barium trapping in the rectocele may be seen. Accord- ing to some authors, these findings may be used in selecting patients for rec- tocele repair (8,39–42). However, we believe, as do many other authors, that the main value of defecography is its objective demonstration of the rec- tocele and concomitant pathology (43,44). There is not always a correlation between the patient’s symptoms and the size of the rectocele or the amount of barium trapping. At defecography, it is important to study the video film because a rectocele is sometimes only seen in the beginning of defecation, and it then may be pushed away at the end of defecation in patients with a concomitant enterocele. Therefore, the rectocele may not be seen and is missed on a spot film taken at the end of defecation.

It has been shown in several studies that it is difficult to detect an ente- rocele on clinical examination (45). On defecography, an enterocele is visu- alized when opacified bowel descends down into the rectovaginal space.

Enteroceles can be large in size, influencing both the vaginal and/or rectal contour, and may sometimes reach deep down towards the perineal body (Figure 3.1(ii).4). An enterocele usually is demonstrated on defecography during rectal evacuation or when evacuation is completed. Some authors recommend a post-toilet film, (a spot film taken when the patient has emptied the bowels in the privacy of a bathroom) because it may some- times be difficult for the patient to empty the rectum in the study situation where enteroceles can then be missed (46). It is well accepted that an ente- rocele may cause symptoms of pelvic pressure or heaviness, but the influ- ence of an enterocele on rectal emptying is unclear (47).

Perineal descent is best estimated on defecography. Whether perineal descent is a “syndrome” (48) or a sign of an underlying functional disorder of evacuation is debated. We believe that it is a sign of weakness of the voluntary muscles of the pelvic floor and that an underlying cause needs to be considered (Figure 3.1(ii).5).

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Variants of the Defecography Technique

Anorectal symptoms often are combined with other symptoms of the pelvic floor as pelvic heaviness, discomfort due to a vaginal protrusion, or functional symptoms including urinary difficulty, incontinence, or dyspare- unia. To obtain a global view of the pelvic floor on radiological investiga- tion, several authors have suggested variants of the basic defecographic technique. Hock et al. (10) introduced colpo-cysto-defecography of the female pelvis and suggested that the uterus and the pouch of Douglas could be recognized by negative contrast where an enterocele was diag- nosed when a broadening of the rectovaginal space was evident. Altringer et al. (11) described “four-contrast defecography” with contrast medium also in the small bowel. The use of small bowel contrast to identify an ente- rocele is preferred because, in patients who have previously undergone pelvic floor surgery, a broad rectovaginal space may consist of scar tissue or fat.

The use of intraperitoneal contrast medium in combination with defecog- raphy is advocated in some institutions (13,49,50). Intraperitoneal contrast medium is instilled by puncture of the abdominal wall in the midline one to two centimeters below the umbilicus under fluoroscopic control. It is important to be aware that this is an invasive technique, however, with the advantage that the peritoneal outline can be directly visualized and a deep pouch of Douglas can be demonstrated at rest or during straining. A deep pouch of Douglas reaching below the upper third of the vagina has been named by us as a peritoneocele (51) (Figure 3.1(ii).7), and a peritoneocele may predispose to enterocele formation. When repeated defecographies using concomitant intraperitoneal contrast medium have been performed, it has been noted that bowel is not present in the peritoneocele at all times, which explains why an enterocele can be missed when intraperitoneal contrast medium is omitted. Visualization of the peritoneal outline also is possible with magnetic resonance imaging (MRI), and this is a less invasive method [see Chapter 3.3(iii)].

Contrast medium in the urinary bladder visualizes the bladder base and the changes in bladder configuration during straining. With a catheter, the urinary bladder is emptied and contrast medium instilled (50 mL usually is sufficient) to fill the dependent part of the bladder. At this stage, vaginal contrast is instilled, and sometimes intraperitoneal contrast as well (52) (Figure 3.1(ii).8). The patient is seated and a spot film is taken at rest and during straining. The cystographic phase should be performed prior to instillation of rectal contrast, as a contrast-filled rectum may prevent the bladder base from descending. Some authors also have drained the bladder before instillation of contrast medium into the rectum to avoid the descend- ing bladder and preventing visualization of an enterocele or minimizing the detected size of a rectocele (15). We have not found this necessary because

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Figure 3.1(ii).7. A 72-year-old woman with two years of increasing symptoms of rectal emptying difficulty. Defecography with contrast medium in the urinary bladder, intraperitoneally, in the vagina, rectum, and the small bowel was performed.

(a) Contrast medium was administered in the small bowel, urinary bladder, intraperitoneally, and into the vagina. A peritoneocele is seen during straining.

(b) Rectal contrast also was administered. A large peritoneocele is demonstrated during straining and evacuation of the rectum. Air-filled bowel is seen descending down into the peritoneocele; namely, this patient has an enterocele. V, vagina; UB, urinary bladder; SB, small bowel; Pc, peritoneocele; R, rectum.

a

b

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Figure 3.1(ii).8. A 62-year-old woman with discomfort due to a vaginal protrusion and rectal emptying difficulty with the need for digitation per vaginam during defe- cation. Radiological investigation with contrast medium in the urinary bladder, intraperitoneally, in the vagina, rectum, and the small bowel was performed.

(a) Contrast medium was administered into the small bowel, urinary bladder, intraperitoneally, and into the vagina. The peritoneal outline was demonstrated and a peritoneocele was easily demonstrated at rest. (b) During straining the perito- neocele enlarges and the bladder base descends.

a

b

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Figure 3.1(ii).8. (c) Rectal contrast also was administered. At rest, there is a bulge of the anterior rectal wall and the peritoneocele is not seen at this point. (d) During straining and rectal evacuation, a rectocele develops and the peritoneocele is once again demonstrated where the bladder base descends. At the end of evacuation, a rectal intussusception reaching down into the anal canal is also evident. V, vagina;

UB, urinary bladder; SB, small bowel; R, rectum; Pc, peritoneocele; Rc, rectocele;

RI, rectal intussusception; arrowhead, peritoneal outline.

c

d

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the volume instilled in the bladder is small and the force from the rectal side is more pronounced.

Defecography and variants of the technique are performed with the patient in the upright position, which is an advantage when studying the alterations in the pelvic peritoneal cavity during rectal emptying. However, it is important to remember that the patient is asked to strain and that a

“normal” evacuation initiated by a defecation reflex is not obtained.

Conclusion

We recommend standard use of contrast medium in the rectum, vagina, and small bowel. However, intraperitoneal contrast medium is preferable in the diagnosis of enterocele and peritoneocele, but this method is more invasive.

Bladder contrast should be used only in patients with complex pelvic floor disorders and/or previous pelvic floor surgery. It is easy to diagnose an ante- rior vaginal wall prolapse at clinical examination, and it is very rare that it consists of other abdominal content than the bladder.

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