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Section VI • Update in the Evaluation of Outlet Obstruction 213
Fig. VI.11. Characteristic elliptical mor-
phology of the internal anal sphincter
(IAS) in a patient with cinrcumferential
mucosal prolapse. EAS external anal
sphincter,MP mucosal prolapse
vector manometry, was significantly increased at
rest, confirming that rectal prolapse alters mainly IAS functions.
Rectocele
Rectocele is defined as ventral displacement of the
anterior rectal wall into the posterior vagina over
a distance of at least 1 cm during straining to defecate in comparison with the resting tone. The
pathogenesis of this disorder remains controversial [21–26]. The concept of the rectocele as a
defect in the integrity of the rectovaginal septum
has been reported by Richardson [22, 23] and
DeLancey [24]; however, there is still controversy
concerning the anatomical importance (or even
the existence) of the rectovaginal septum [25, 26].
Recently,Aigner et al. [25] performed macroscopic dissections on embalmed human pelvis and
plastination histology of 40 fetal and newborn
pelvic specimens. By means of conventional and
immunohistochemical staining methods using
monoclonal and polyclonal antibodies for tissue
analysis and neuronal labeling, the authors were
able to demonstrate that the rectovaginal septum
is formed of dense collagenous and elastic fibers
and longitudinal smooth muscle bundles originating from the external longitudinal muscle
layer of the ventral rectal wall.The septum consti-
tutes an incomplete partition between the rectum
and the vagina, and it is completed by the perineal
body caudally [25]. Leffler et al. [26] reported that
laterally, the rectovaginal septum attaches to the
pelvic sidewall. They reported that a significant
percentage of the specific defect in the rectovaginal fascia have been found to occur laterally, representing a detachment of the septum from the
pelvic sidewall.
In normal women, the septum can be visual-
ized by EAUS as a V-shaped hyperechoic layer
dividing the vagina and the rectum (Fig. VI.12).
The septum appears decreased in thickness
(Fig. VI.13) in patients with rectocele, or it may
appear interrupted in the midline (Fig. VI.14). A
ventral displacement or a bulging of the anterior
rectal wall during straining may also be visualized
by EAUS (Fig. VI.15). Barthet et al. [13] reported
that DAE is a reliable procedure for diagnosing
rectocele, with a sensitivity of 86% and accuracy
of 87%. The rate of concordance between DAE and
defecography was 57%. Recently, Beer-Gabel et al.
[18] assessed the feasibility of DTP-US in the diagnosis of pelvic floor disorders. Rectoceles, peritoneoceles, enteroceles, and rectoanal intussusception were readily identified using DTP-US. This
technique will be described in a different chapter
of this section.
The concept of the rectocele as a consequence
of a primary abnormality of the rectal wall with
214 Benign Anorectal Diseases
Fig.VI.12. In a normal woman, the septum (RVS rectovaginal
septum) can be visualized as a V-shaped hyperechoic layer
dividing the vagina (V) and the rectum (R)
a
Fig. VI.13. The septum appears decreased in thickness in a
patient with rectocele
Fig. VI.14. The septum appears inter-
rupted in the midline in a patient with
rectocele (a). The characteristic five-layer
structure of the rectal wall is disrupted:
the mucosa exceeds the normal thickness,
and the muscularis propria is irregular
and interrupted. Three-dimensional
reconstruction on the sagittal plane (b).
RV S rectovaginal septum, V vagina, MP
b
muscularis propria
Section VI • Update in the Evaluation of Outlet Obstruction 215
Fig.VI.15. Bulging of the anterior rectal wall during straining
in a patient with rectocele
disruption of the muscularis propria layer has been
recently reported [27]. Interestingly,in women with
rectocele, ERUS has been able to demonstrate that,
along with the discontinuity of the rectovaginal
septum, the characteristic five-layer structure of
the rectal wall is disrupted: the mucosa exceeds the
normal thickness, and the muscularis propria is
irregular and interrupted (Fig. VI.14).
Enterocele
An enterocele is a hernia of intestinal loops into
the cul-de-sac of Douglas, which protrudes into
the vagina or the rectum. They may accompany
other pelvic and anorectal disorders or cause outlet obstruction. EAUS has the capability of diagnosing small, occult enteroceles. Three-dimensional reconstructions on axial and sagittal planes
provide images of intestinal loops entering into
the rectogenital space in patients with rectocele
(Fig. VI.16). By using rectal ultrasonography,
Vierhout et al. [19] correctly confirmed the existence of an enterocele in 27 of the 29 patients with
this condition. Halligan et al. [15] examined 17
women with vaginal endosonography to diagnose
enterocele, and the findings were compared with
proctography. A diagnosis of enterocele was confirmed if bowel prolapsed into the rectogenital
space during straining, obscuring the rectum
(Fig. VI.17). The authors reported a sensitivity of
100% and specificity of 82%, with a positive predictive value of 75% and negative predictive value
of 100%. Karuas et al. [12] investigated the use of
DAE to detect this disorder. In patients with enterocele, the pouch of Douglas opened during
straining, and intestinal loops moved toward the
anus (Fig.VI.18). The diagnosis of enteroceles was
confirmed in all patients by defecography, giving
a specificity of 100%.
a
Fig. VI.16. Intestinal loops (arrows) visualized by endorectal ultrasonography in a patient with rectocele. Three-dimensional
reconstruction on axial (a) and sagittal (b) planes
b
216 Benign Anorectal Diseases
Small bowel loops
Anal endosonography probe
in vagina
a
Fig. VI.17. Schematic representation of
diagnosis of enterocele using transvaginal ultrasonography
Fig. VI.18. Endosonographic sagittal
scan of a normal women during maximal
straining (a). Endosonographic scan of a
patient with an enterocele during maximal straining showing the deep protrusion of intestinal loops into the Douglas,
pushing the vagina in a horizontal posi-
b
tion (b).(Modified from [12])
Section VI • Update in the Evaluation of Outlet Obstruction 217
Pelvic Floor Dyssynergy
Pelvic floor dyssynergy is the most prevalent functional cause of dyschezia [2]. The patient does not
sufficiently relax and sometimes even paradoxically contracts the anal sphincter muscles and puborectalis during straining to defecate. Dynamic
ultrasound examination has been proved valuable
in diagnosing this disorder [14].Van Outryve et al.
[14] evaluated 20 patients with a medical history of
dyschezia. They found that the anal sphincter
became paradoxically shorter and/or thicker during straining (versus the resting state) in 85% of
patients but in only 35% of control subjects.
Changes in sphincter length were statistically sig-
References
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Christiansen J (1993) Dynamic anal manometry in the
assessment of patients with obstructed defecation. Dis
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2. Fucini C, Ronchi O, Elbetti C (2001) Electromyography
of the pelvic floor musculature in the assessment of
obstructed defecation symptoms. Dis Colon Rectum
44:1168–1175
3. Felt-Bersma RJF, Luth WJ, Janssen JJWM, Meuwissen
SGM (1990) Defecography in patients with anorectal
disorders. Which findings are clinically relevant? Dis
Colon Rectum 33:277–284
4. Rentsch M, Paetzel Ch, Lenhart M et al (2001)
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5. Burnett SJ, Spence-Jones C, Speakman CT et al (1991)
Unsuspected sphincter damage following childbirth
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sphincter tears in patients with rectal prolapse and
incontinence. Colorectal Dis 5:544–548
7. Nielsen MB, Rasmussen OO, Pedersen JF, Christiansen
J (1993) Anal endosonographic findings in patients
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Endosonography of the anal sphincters in solitary rectal ulcer syndrome. Int J Colorectal Dis 10:79–82
9. Poen AC, de Brauw M, Felt-Bersma RJ et al (1996)
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nificantly different (p<0.01) in patients compared
with control subjects. In the patients with
dyschezia, a decrease in length (from 41 mm to
38 mm) and increase in thickness (from 8 mm to
10 mm) of the puborectalis was demonstrated during straining versus the resting state. Both the
changes in length and thickness of the puborectalis were significantly different (p<0.01) in patients
versus control subjects. These data indicate that in
patient with pelvic floor dyssynergy, not only the
anal sphincter but also the puborectalis muscle
paradoxically contract instead of relaxing during a
straining effort. The anorectal angle does not
increase, preventing the descent of feces from the
rectum into the anal canal.
Clinical outcome and anorectal function tests. Surg
Endosc 10:904–908
10. Dvorkin LS, Chan CLH, Knowles CH et al (2004) Anal
sphincter morphology in patients with full-thickness
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11. Damon H, Henry L, Roman S et al (2003) Influence of
rectal prolapse on the asymmetry of the anal sphincter in patients with anal incontinence. BMC
Gastroenterol 3:23–29
12. Karuas M, Neuhaus P, Wiedenmann B (2000)
Diagnosis of enteroceles by dynamic anorectal
endosonography. Dis Colon Rectum 43:1683–1688
13. Barthet M, Portier F, Heyries L (2000) Dynamic anal
endosonography may challenge defecography for
assessing dynamic anorectal disorders: results of a
prospective pilot study. Endoscopy 32:300–305
14. Van Outryve SM, Van Outryve MJ, De Winter BY,
Pelckmans PA (2002) Is anorectal endosonography
valuable in dyschesia? Gut 51:695–700
15. Halligan S, Northover J, Bartram CI (1996) Vaginal
endosonography to diagnose enterocele. Br J Radiol
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16. Tunn R,Petri E (2003) Introital and transvaginal ultrasound as the main tool in the assessment of urogenital
and pelvic floor dysfunction: an imaging panel and
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218 Benign Anorectal Diseases
pelvic floor disorders. Pilot study. Dis Colon Rectum
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VI.3.
Clinical Dynamic Transperineal
Ultrasonography in Proctologic Practice:
the Case for its Use in Patients Presenting
with Evacuatory Difficulty
A.P. Zbar, M. Beer-Gabel
Dynamic transperineal ultrasonography (DTP-US)
is a relatively simple technique that has only recently been exploited to assess the component parts of
the anterior, middle, and posterior pelvic compartments and their interaction during provocative
maneuvers such as straining and simulated defecation in patients presenting to gynecologists or coloproctologists with evacuatory dysfunction [1, 2].
This approach provides comparative images to
those achieved with axial endoanal ultrasound
(EAUS) transducers for the assessment of morpho-
logic integrity of both the internal (IAS) and external (EAS) anal sphincters; [3] however, our group
and others have defined a clinical role for DTP-US
in dynamic mode during forcible straining as a
principal adjunct to the clinical evaluation of
patients presenting to specialized clinics with evacuatory difficulty and obstructed defecation [4, 5].
There is generally a poor correlation between
the symptoms attributed to pelvic floor dysfunction and radiologically demonstrable findings [6],
where most studies have shown that virtually all
patients presenting with evacuatory difficulty have
a multiplicity of pathologic problems ranging
across each pelvic compartment [7]. Traditionally,
evacuation proctography (or one of its extended
techniques, including opacification of the small
bowel, bladder, vagina, and even the peritoneal
cavity), has been used to define the presence of
major morphological anomalies – most notably,
rectocele, enterocele, rectoanal intussusception,
rectal prolapse, and descending perineum syn-
drome – which are then attributed by the clinician
as relatively dominant pathologies implicated in
the evacuatory symptomatology and then accordingly treated [8]. What is clear is that a multidisciplinary approach, involving gastroenterologists,
surgeons, gynaecologists, urologists, and biofeedback technologists, is required for these patients
with multicompartmental disease [9] and that
even within defined disorders such as rectocele,
the preoperative assessment using different
modalities may subcategorize patients into groups
with different management solutions [10].
This chapter defines the indications, experience, and pitfalls of DTP-US, describing the basic
technique, advantages, and limitations in specific
pelvic floor disorders and accuracy in those
patients presenting to a pelvic floor dysfunction
unit with primary disorders of rectal evacuation.
Technical Features of DTP-US
The technique is simple when compared with
endoluminal sonography although its interpretation is comparatively difficult, with a substantial
leaning curve. No specific preparation is required,
and it is wise if facilities exist to videotape the
procedure for retrograde and orthograde
scrolling akin to that routinely used in defecography.DTP-US is performed with a curvilinear 7.5 or
10 MHz probe after liberal application of acoustic
gel to the perineum. It is wise to insert by Luer
220 Benign Anorectal Diseases
syringe a minimum of 50 ml intravaginally as well
as into the rectum. Here, there have been claims
that excessive distension of either organ may create a “crowded pelvis syndrome” [11] and obscure
some diagnoses of clinical importance, most
notably rectocele and enterocele, but this has not
been our experience, where the amount of
intravisceral gel has been varied without an effect
on the principal diagnoses. For the diagnosis of
both enterocele and peritoneocele, it is advisable
that the patient ingest 100 ml of water-soluble
Gastrografin (Schering, UK) diluted 1:1 with tap
water 1 h prior to the examination. For sterility,
the probe may be covered by an oversized con-
dom instilled with acoustic gel, or with a latex
glove. Patients are traditionally examined in the
left lateral position (although it is recognized that
this position, along with its use for provocative
maneuvers such as gel evacuation or forcible
straining, is not physiological), as it provides a
standardized interpretation of images for all
pelvic floor compartments. Comparison between
this technique and dynamic magnetic resonance
imaging (MRI) for patients presenting with evacuatory difficulty has not been performed, but
here, conditions that appear at the end of defecation, (such as rectal prolapse and rectoanal intussusception) will be poorly diagnosed because of
External
anal
sphincter
Internal
anal
sphincter
a
Internal
anal
sphincter
Puborectalis
en face
b
Section VI • Update in the Evaluation of Outlet Obstruction 221
Contrast-filled
vagina
Rectovaginal
U
B
c
septum
Air-filled
rectum
Vesicourethral
junction
d
Fig. VI.19. Axial transperineal sonogram showing the complete hypoechoic ring of the internal anal sphincter (IAS) and the
hyperechoic flattened external anal sphincter (a).Sagittal transperineal ultrasound (TP-US) showing the hypoechoic IAS in profile as a continuation of the air-filled rectum. The puborectalis muscle is seen as a bright elliptical structure en face (b).
Transperineal ultrasound of the anterior perineal compartment showing the vesicourethral junction (c) (B bladder, U urethra).
TP-US showing the normal rectovaginal septum as the territory between the vagina (containing acoustic gel) and the air-filled
rectum (d)
the nonphysiological position. Comparative studies between conventional and upright DTP-US or
with open-architecture MRI are awaited [12].
Examination of the anus is made with the trans-
ducer initially applied transversely to the perineal
body, identifying the axial view of the anus using
the landmark of the hypoechoic ring of the IAS in
an image similar to that obtained in the midanal
canal using endoanal ultrasonography
(Fig. VI.19a). The transducer is then turned 180° to
222 Benign Anorectal Diseases
a
Rectovaginal
septum
Small bowel loops which
do not enter the
rectovaginal septum
b
Fig. VI.20. In order to diagnose a peritoneocele, the rectovaginal septum is expanded beyond 2 cm in maximal diameter but is
empty (a). An enterocele is defined by the presence of peristaltic, contrast-filled, enteric loops occupying the expanded rectogenital septum (b) (R rectum, SB small bowel, V vagina, BL bladder)
obtain a sagittal view of the contrast-filled rectum,
with extension of the hypoechoic internal anal
sphincter appearing above and below the anal
canal in profile.The anorectal junction is well seen,
with the bright hyperechoic elliptical bundle of the
puborectalis sling demonstrable in relief
(Fig. VI.19b). In the sagittal mode, the examination
should proceed to identify the brilliantly hyperechoic pubis and is then worked back by downward
movement of the transducer against the perineum
to locate the hypoechoic bladder and the urethrovesical junction (Fig. VI.19c), the position and
movement of which will be dependent upon the
filling status of the bladder at the time of the investigation [13]. Transperineal sonography has been
used definitively along with transintroital sonography for the objective diagnosis of urinary stress
incontinence [14, 15]. The middle compartment is
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