Jul 2, 1997 - Senior House Officer. H Blake FRCR. Consultant Radiologist. R I Swift BSc MS FRCS. Consultant Surgeon. Departments of Surgery and ...
Ann R Coll Surg Engl 1998; 80: 40-45
prospective audit of the usefulness of evacuating proctography
A
H J S Jones
FRCS Senior House Officer
H Blake
FRCR Consultant Radiologist
R I Swift
BSc MS FRCS Consultant Surgeon
Departments of Surgery and Radiology, Mayday University Hospital, Thornton Heath, Surrey
Key words: Evacuating proctography; Audit
Fifty-nine evacuating proctograms were performed over a 4 month period. We sought to identify how useful this technique is in diagnosing the cause of various anorectal symptoms and indicating which treatment option may be beneficial to the patient. The main reasons for referral were faecal soiling (60%) and obstructed defaecation (47%). Of the proctograms, 90% revealed some pathology. The most common abnormalities detected were rectocele (56%), rectal intussusception (39%), enterocele (19%) and rectal prolapse (12%). Of the patients, 45% were treated with an operation specific to the pathology detected on the proctogram; 29% did not require any active treatment and the remainder were managed with biofeedback conditioning or injection sclerother-
defaecation. They included 43 females (74%) and 15 males (26%). The females had a median age of 59 years (range 33-89 years) and the males had a median age of 63 years (range 32-73 years).
Proctography Patients were prepared for the proctogram with oral contrast and glycerine suppositories. Thick barium paste was introduced into the rectum while the patient was in the left lateral position. The patient then sat on a commode and was instructed to evacuate as rapidly and completely as possible. This was screened with fluoroscopy and recorded on video.
apy.
Evacuating proctography is of value in providing a diagnosis in patients with anorectal symptoms and thereby allowing specific treatment, operative or nonoperative, to be directed to the underlying pathology.
Evacuating proctography is a valuable adjunct in the diagnosis of functional rectal and anal disorders. This technique has recently been introduced at this hospital, and we have reviewed the usefulness of this technique in its first few months.
Patients and methods In all, 59 proctograms were performed in 58 patients over 4 month period. These patients had been referred to the colorectal outpatient clinic with various disorders of
a
Presentation of patients The most common presenting symptoms were of faecal soiling in 35 (60%) and obstructed defaecation in 27 (47%). Other presenting symptoms included irregular bowel habit 12 (21 %), manual pressure required to evacuate 11 (19%), pain 2 (3%) and rectal prolapse 4 (7%).
Most patients had other investigations performed as well as the proctogram to elucidate the cause of their symptoms. These most commonly included barium enema in 36 (62%) and anorectal manometry in 24 (41%). Colonoscopy (7, 12%) and endoanal ultrasound (4, 7%) were also performed in some
Results Pathology
Correspondence to: Mr R I Swift, Mayday University Hospital, London Road, Thornton Heath, Surrey CR7 7YE
Only six proctograms were completely normal, giving diagnostic yield of 90%.
a
Evacuating proctography
Rectocele This was the most common abnormality detected, with 33 proctograms (56%), in 32 patients demonstrating a rectocele. All but one of these were female. The presenting symptom was soiling in 18 (56%) and obstructive defaecation in 16 (50%), seven of whom reported requiring digital pressure to effect defaecation. One presented with urgency and another with abdominal pain. The rectocele was the sole abnormality shown in six patients. Associated findings included rectal intussusception in 17 (52%), enterocele in 8 (24%), rectal prolapse in 3 (9%), abnormal perineal descent in 3 (9%) and mucosal prolapse in 2 (6%). There were 18 (55%) graded as small, 11 (33%) as moderate, and 4 (12%) as large. The rectocele was noted not to empty in 22% of small, 64% of moderate and 75% of large rectoceles.
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(a)
(b)
(a)
Figure 2. Proctogram taken in the lateral seated position. (a) Shows a rectocele (seen as a bulge to the left) and a rectal intussusception (the notch in the upper rectal wall). In (b) the intussusception has progressed downwards into the anal canal.
In all, 13 patients had the rectocele repaired surgically, 11 laparoscopically and two via an open procedure. Of these, four had a concomitant rectopexy for associated pathology. Of those who did not require surgical repair of the rectocele, nine had surgery for other anorectal pathology, most commonly a rectopexy. The remaining 11 were managed conservatively.
(b) Figure 1. Proctogram taken in the lateral seated position. Contrast is seen in the small bowel and rectum. (a) Shows a rectocele (anterior bulge of rectum) and an enterocele (descent of small bowel). (b) The rectum has failed to empty owing to compression by the enterocele.
Enterocele An enterocele was identified in 11 patients (19%). These were all female. The presenting symptom was obstructive defaecation in 8 (73%) and soiling in 4 (36%). Enterocele was the sole pathology shown in only one patient. Eight proctograms (73%) showed an associated rectocele, 4 (36%) rectal intussusception and 3 (27%) a rectal prolapse. Two enteroceles were graded as small, five moderate and four large. Treatnent in five was a rectopexy (laparoscopic in three, open in two), one of whom had a concomitant
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rectocele repair. Three patients had surgery for other pathology, two for a rectocele and one a sphincter repair. Three were managed conservatively.
Rectal intussusception A rectal intussusception was demonstrated in 23 patients (39%); 4 males and 19 females. The presenting symptoms among this group were soiling in 11 (48%), obstructive defaecation in 9 (39%), urgency in 3 (13%), per rectal bleeding in one and pain in two. The intussusception was an isolated finding in four patients; 17 (74%) showed a coexistent rectocele and 4 (17%) an enterocele. Abnormal perineal descent, incontinence, and a mucosal prolapse were each detected in one patient. Of the intussusceptions, 15 (65%) were graded as small, 6 (26%) as moderate and 2 (9 %) as large. Management involved rectopexy in nine, performed laparoscopically in eight. Of these, three were combined with a rectocele repair. A further four patients had rectocele repair as their sole operative management and 10 were treated conservatively. A mucosal fold, which may represent an early intussusception or altematively be a normal finding, was reported in three cases, two males and one female. The presenting symptom was difficulty in defaecation in all three. This was the sole pathology seen in two patients, the other showing a rectocele. Management was conservative in two patients and one underwent repair of the rectocele. Rectal prolapse Rectal prolapse was identified in 7 (12%) proctograms. These included one male and six females. In five of these the presenting symptom was a prolapse, requiring manual reduction, and was associated with soiling in three. The other two complained of obstructive defaecation. Rectal prolapse was the only pathology detected in one proctogram, three showed rectocele, three enterocele, one abnormal perineal descent and two were incontinent. Two prolapses were graded small, two moderate and three large. Five have been treated with rectopexy, laparoscopic in two, and open in three. In two cases, surgery was combined with a procedure for other pathology, one for rectocele and one hysterectomy. Two were managed conservatively.
Perineal descent Excessive perineal descent was observed in four proctograms. These were all female. Presenting symptoms were soiling in three, prolapse in one and obstructed defaecation in one. All demonstrated other pathology, rectocele in three, rectal prolapse in one and rectal intussusception in one. Two were managed with a rectopexy, the other two conservatively.
Incontinence Four patients were incontinent during the procedure, all of whom were female. Presenting symptoms were soiling in three and obstructed defaecation in two. Other pathology was present in all proctograms; rectal prolapse in two, intussusception in one, musocal prolapse in one and abnormal perineal descent in one. Two were managed by rectopexy, the other two conservatively.
Constipationldifficulty in evacuation Eight proctograms demonstrated difficulty in evacuation, with five showing slow evacuation, one incomplete evacuation and two unable to evacuate, in one owing to anismus. Other findings were present in four, comprising rectocele in three, mucosal fold in two, intussusception in one and marked perineal descent in one. Normal proctogram Six proctograms showed no abnormality, five male and one female. One-third of the males examined had a normal proctogram, whereas the same applied to only 2% of females. Symptoms in this group were soiling in five and constipation in one. One was treated with a haemorrhoidectomy, the other five conservatively.
Management In 26 patients (45%) the proctogram demonstrated pathology to explain the symptoms which was treated with a specific operation. In other patients pathology was identified but managed conservatively because of minor symptoms only, other medical problems which precluded surgery or patient choice.
Discussion Mucosal prolapse Five proctrograms demonstrated a musocal prolapse, three female and two male. The presenting symptom was soiling in all five; one also complained of obstructed defaecation. Mucosal prolapse was the sole pathology seen in two. The others showed rectocele in two, rectal intussusception in one and incontinence in one. Management consisted of injection sclerotherapy in three, rectopexy in one and was conservative in one.
This study reveals a high incidence of pathological findings in proctograms performed on those who present with disorders of defaecation, particularly obstructive defaecation and faecal soiling. In those with obstructive symptoms, the presence of detectable pathology in the majority was not unexpected. In those who present with soiling, impariment of anal sphincter function may be thought more likely. However, if sphincteric function was clinically assessed as normal
Evacuating proctography we performed a proctogram as an abnormality in evacuation may permit subsequent seepage of the incompletely cleared rectal contents resulting in soiling.
Rectocele Rectocele is a bulging of the rectum outside the line of its wall. It usually affects the anterior wall and most commonly occurs in multiparous women who have sustained damage to the rectovaginal septum during childbirth (1,2). However, small rectoceles are also found in nilliparous women and men (3). Chronic straining is the likely aetiological factor in this group (4). The incidence of rectocele in our study population was 56%. This is somewhat higher than other series, Mellgren et al. (5) reported 27%, and Agachan et al. (6) 41%. The symptoms of rectocele include obstructive defaecation, incomplete evacuation which may be followed by faecal soiling, and the need to apply digital pressure to the bulging posterior vaginal wall to effect defaecation. Rectoceles also occur in asymptomatic subjects (3). Proctograms are more reliable in detecting the presence of a rectocele than physical examination (7) and give more accurate information on the size and degree of emptying of the rectocele. Incomplete emptying is more common in larger rectoceles (5), as our results demonstrate. Halligan and Bartram (8) found that the pressure within a rectocele that traps barium during defaecation is much lower than in the rectum proper, whereas there was no pressure differential in the rectoceles that did empty, suggesting that the non-emptying rectocele lies outside the pressure zone generated during defaecation. However, they did not find any correlation between emptying of the rectocele and symptoms. Many of our subjects had associated pathology, particularly enterocele and rectal intussusception which is consistent with a common underlying pathology of weakness in the anterior rectal wall (9). Surgical repair of rectocele has been associated with various problems in the past (10), but more recent studies have achieved good outcome when patients were carefully selected for surgery (11,12). The surgical treatment we used for those with rectoceles whose symptoms warranted surgery was laparoscopic reconstruction of the rectovaginal septum with a synthetic mesh.
Enterocele Enterocele is a herniation of the peritoneal pouch of Douglas into the area between vagina and rectum (13). It is suggested on proctography by a separation of the vagina and rectum of greater than 2 cm during straining, but confirmation requires seeing small bowel loops in this space (14). This necessitates contrast in the small bowel. Enteroceles are more common in the presence of previous pelvic surgery such as hysterectomy. An enterocele was demonstrated in 19% of our subjects, a simlar proportion to other studies (5), and in most there was associated pathology. Only one of 11 in our series occurred as an isolated finding.
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As for rectocele, a number of operative techniques for enterocele repair have been reported. These include several transvaginal procedures, particularly useful in the presence of associated gynaecological or urological symptoms (13). Rectopexy has also been shown as an effective option in enterocele repair (15). Almost half of our patients underwent surgical repair of enterocele by rectopexy, either open or laparoscopic.
Rectal intussusception Rectal intussusception is defined as an invagination of the rectal wall on straining. It usually begins 6-8 cm above the anal canal, and may be anterior, posterior or circumferential. If it passes down through the anal canal it becomes a rectal prolapse (14). Small intussusceptions can be difficult to distinguish from normal mucosal folds on a proctogram. Intussusception was the second most common abnormality detected in our series, occurring in 39%, which is somewhat higher than other series-Mellgren et al. (5) reported a 31% incidence and Agachan et al. (6) 30%. The symptoms attributable to intussusception include obstructive defaecation and incontinence. The incontinence may be caused by pelvic neuropathy resulting from chronic straining (4). Intussusception has also been demonstrated in up to 50% of proctograms in asymptomatic subjects (3). Siproudhis et al. (7) have suggested that proctography is not required in the investigation of intussusception as large intussusceptions can be detected clinically via sigmoidoscopy, and small intussusceptions are not significant and do not require treatment. However, intussusception is often associated with other abnormalities, in particular enterocele owing to the intussuscepting rectum pulling down the anterior rectal wall (14) and solitary rectal ulcer syndrome owing to the association of both with chronic straining (4). A rectocele may also be exacerbated by an intussusception that traps material in the rectocele during straining (14). In our series, 74% of intussusceptions were associated with a rectocele and 17% with an enterocele. Although rectopexy is of clear benefit in rectal prolapse, its role in the treatment of intussusception is not so clear. Symptoms of faecal incontinence are more amenable to surgery than those of constipation (16) and it has been suggested that the mechanism for improvement of symptoms after rectopexy in patients with intussusception may differ from that in prolapse (17). Rectal prolapse The incidence of prolapse in our series was 12%, comparable with other series (5,6). Although rectal prolapse is usually obvious on clinical examination, a proctogram can be useful to distinguish a mucosal from a full-thickness rectal prolapse, to define any associated pathology and also when a prolapse cannot be detected clinically despite a typical history (5). Rectopexy was the treatment used in five of the seven patients with rectal prolapse in our series. Several operative techniques for
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repair are available, with satisfactory results (18). Recovery of function of the internal anal sphincter after rectopexy is thought to be a major factor in the improved continence (17,18).
Perineal descent Abnormal perineal descent was noted in four proctograms (7%), a figure comparable with other series (5). This descent is a reflection of decreased muscle tone in the pelvic floor, which also shows itself in a widened anorectal angle. The puborectalis muscle normally maintains the anorectal angle at approximately 900 and relaxes during defaecation to allow an angle of closer to 1400 (19,20). Incontinence is therefore a common symptom. Abnormal perineal descent is associateed with damage to the pudendal nerve, both the motor and sensory fibres (21), but it is not clear whether the descent results from nerve damage, or the nerve is damaged by stretching resulting from chronic straining. Childbirth may also damage the pudendal nerve (22). All the proctograms showing abnormal perineal descent in our series also showed other pathology, an indication of general weakness in the tissues. Three of the four proctograms showed rectocele. In the study of Mellgren et al. (5), rectocele was the only abnormality signficantly more common in those with abnormal perineal descent39% vs 26% in those with no abnormal descent-which may reflect a common aetiological factor such as chronic straining or childbirth (23). There is no effective surgical treatment currently available for this problem.
Non-relaxing puborectalis syndrome In our series, three patients were unable to evacuate the barium. However, only one of these demonstrated anismus with increased contraction in the puborectalis and no perineal descent. This patient presented with difficulty in defaecation, tenesmus and rectal bleeding. Previous sigmoidoscopy and biopsy had demonstrated solitary rectal ulcer syndrome and rectal intussusception. Halligan et al. (24) have shown a 23% incidence of impaired evacuation and 68% incidence of rectal intussusception or prolapse in those with solitary rectal ulcer syndrome. The intussusception detected clinically in our patient was not demonstrated on proctography as she failed to evacuate. Many of the pathological findings that can be seen on proctography only become evident during evacuation and therefore may be missed if the subject is unable to defaecate. The findings on proctography in non-relaxing puborectalis syndrome are a failure of the anorectal angle to increase on straining and a prominent posterior impression at the anorectal junction from the puborectalis muscle on straining (4). Pelvic floor descent may be absent, normal or excessive, and it has been suggested that this may reflect how long-standing the problem is, with chronic straining causing pudendal neuropathy and pelvic floor weakness, resulting in progressive perineal descent (25).
Endoanal ultrasonography may also have a role in the investigation of obstructed defaecation. It has been used in incontinent patients to demonstrate specific defects in the anal sphincter (26), and more recently advocated in the presence of obstructive defaecation to identify intemal sphincter hypertrophy as a cause of symptoms (27). Nielson et al. (27) also found the external sphincter to be thicker in those with obstructed defaecation compared with normals. Biofeedback training has been shown to be effective in treating patients with obstructive defaecation owing to pelvic floor spasm (28).
Methods of proctography We used barium contrast for our proctograms. An alternative is radioisotope proctography (29). This does not give such clear anatomical information, and will not demonstrate minor abnormalities such as small rectal intussusception, but is able to give more quantitative information regarding the amount of contrast excreted, so allowing accurate estimation of completeness of evacuation.
Conclusion In conclusion, we consider evacuating proctography to be a valuable investigative tool in patients presenting with defaecatory disorders, as a cause for the symptoms is demonstrated in many cases and often the pathology is amenable to a specific surgical operation. When a diagnosis has been made on the basis of clinical findings, proctography can confirm and quantify the problem and show any associated pathology. Although some findings are not amenable to surgery, providing the patient with an explanation for their symptoms is often beneficial and in many cases effective non-operative treatment is also
available.
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20 Felt-Bersma RJF, Luth WJ, Janssen JJWM, Meuwissen SGM. Defecography in patients with anorectal disorders: which findings are clinically relevant? Dis Colon Rectum 1990; 33: 277-84. 21 Gee AS, Mills A, Durdey P. What is the relationship between perineal descent and anal mucosal electrosensitivity? Dis Colon Rectum 1995; 38: 419-23. 22 Snooks SJ, Setchell M, Swash M, Henry MM. Injury to innervation of pelvic floor sphincter musculature in childbirth. Lancet 1984; 2: 546-50. 23 Yoshioka K, Matsui Y, Yamada 0 et al. Physiologic and anatomic assessment of patients with rectocele. Dis Colon Rectum 1991; 34: 704-8. 24 Halligan S, Nicholls RJ, Bartram CI. Evacuation proctography in patients with solitary rectal ulcer syndrome: anatomic abnormalities and frequency of impaired emptying and prolapse. AIR 1995; 164: 91-5. 25 Papachrysostomou M, Smith AN, Merrick MV. Obstructive defaecation and slow transit constipation: the procotographic parameters. Int Colorectal Dis 1994; 9: 115-20. 26 Law PJ, Kamm MA, Bartram CI. Anal endosonography in the investigation of faecal incontinence. Br J Surg 1991; 78: 312-14. 27 Nielsen MB, Rasmussen 00, Pedersen JF, Christiansen J. Anal endosonographic findings in patients with obstructed defaecation. Acta Radiol 1993; 34: 35-8. 28 Papachrysostomou M, Smith AN. Effects of biofeedback on obstructive defecation-reconditioning of the defecation reflex? Gut 1994; 35: 252-6. 29 Papachrysostomou M, Griffin TMJ, Ferrington C, Merrick MV, Smith AN. A method of computerised isotope dynamic proctography. Eur J Nucl Med 1992; 19: 431-5.
Received 2 July 1997
