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consultation to the general practitioner.
9,30
The impact of this cond ition on health
resources is also difficult to asse ss, although up to 8.4% sufferers reported that they were
currently too ill to work or attend school in the classic US householder study.
9
This apparent disability is poorly represented by the small percentage (17%–20%) of patients reporting their symptoms to a physician.
9,12,30
Both sexes seem to be equally affected.
12,30
19.3.3 Pathophysiology and Predisposing Conditions
Smooth anal sphincter spasm is assumed to be the pathophysiological basis for proctalgia
fugax, although there is no definitive evidence for this hypothesis.
12,13
This spasm has been
inconsistently observed during acute pain episodes by ARM measures of increased resting
pressure and anal high-amplitude slow waves.
1,13
Both findings are thought to be influenced by sympathetic activity, which may correlate with the frequent finding of psychological disturbances in these patients.
30
In a recent prospective study of 170 patients with
functional anorectal pain, 33% of patients with proctalgia fugax had a higher internal anal
sphincter thickness and anal resting pressure compared to 9% of patients with CP.
30
Moreover,patients with a family history of similar symptoms were more likely to have proctalgia
fugax, higher resting pressures, and internal anal sphincter thickness compared with those
without a family history of these symptoms.
30
Thaysen suggested that the pain might be due
to the compressive action of a spastic anal sphincter on a hemorrhoidal tumor, but this
speculation has not been substantiated in clinical practice.
4,12
Takano reported on 55 proctalgia fugax patients where the pain could be reproduced by palpation of the pudendal
nerve suggesting pudendal neuralgia could be a relevant comorbidity.
24
After administration of a nerve block, symptoms disappeared completely in 65% and decreased in 25% of
patients.
24
Unfortunately these encouraging results have not been replicated.12Kamm first
described a rare internal anal sphinctermyopathy that causes proctalgia fugax and constipation.
31
It is an autosomal dominantly inherited disease where anal imaging shows
marked hypertrophy of the internal sphincter, and histology shows vacuolar changes with
polyglucosan inclusion bodies or amyloid-like PASpositive bodies.
31
In these patients, constipation has been improved by internal anal sphincter myomectomy, which was not as
effective in resolving pain.
31
Psychological testing suggests that patients are perfectionistic,
anxious, and hypochondriac with a higher incidence of neurotic symptoms in childhood.
12,30
However, a causal relationship has not been established and whether stressful
life events trigger the symptom is a matter of debate.
32
19.3.4 Clinical Presentation
Proctalgia fugax is commonly described by patients as sudden, severe, nonradiating pain
in the anorectal area.
4
The pain may be reported as cramping, stabbing, or spasm-like in
the majority of cases.
33
The pai n rating may range from uncomfortable to unbearable.
Pain duration should be <30min according to Rome IV criteria.
8
However, in a recent prospective study of 54 proctalgia fugax patients, although the average pain duration was
15min, the range varied from a few seconds to 90 min.
33
Patients need to be asymptomatic
244 ANORECTAL DISORDERS
between attacks, otherwise a diagnosis of CP has to be considered. Concomitant symptoms are rare, but might be severe.
32,33
Nausea and vomiting, profuse sweating, and faint-
ness have all been described during severe attacks.
33
Prolonged sitting, sexual intercourse,
stress, and defecation may all act as predisposing factors
32,33
and passing rectal gas and
anal digitation may ease the pain in selected patients.
13,32,33
Historically pain attacks are
reported predominantly at nighttime.
4,12
However, a recent study failed to support this
finding suggesting the possibility that patients remember their nocturnal attack better.
33
Proctalgia fugax tends to relapse, but pain occurs unpredictably at irregularly spaced time
intervals ranging from 1 to 180 times per year.
33
19.3.5 Diagnostic Tests
Patients with proctalgia fugax are usually asymptomatic during consultation and diagnosis relies heavily on eliciting a detailed clinical history.
8,12
The sufferer should be encouraged to describe pain characteristics and whether or not complete well-being is evident
between attacks. Comorbid constipation and a family history of anorectal pain should be
investigated to entertain the rare diagnosis of vacuolar internal anal sphincter myopathy.
31
DRE should be performed on any consulter to exclude minor anal pathology (i.e.,
fissure, thrombosed hemorrhoids) and rectoanal malignancy. Anoscopy and proctoscopy
are helpful tools to implement diagnosis.
32
Sigmoidoscopy can confidently exclude
inflammatory bowel disease, ischemic colitis, and malignancy.
32
In the authors’ experience, suspicion of a rare hypertrophic myopathy of the internal anal sphincter is raised
in the skilled examiner when appropriate.
19.3.6 Management
Most patients with proctalgia fugax never consult physicians because the episodes of pain
are of short duration, infrequent, and spontaneously resolve.
8,12
For those who do, simple
reassurance and avoidance of trigger events, if any, are first-line treatment.
12,32
This
approach is likely to be effective in patients with mild symptoms, but it may be perceived
as an excuse to delay more invasive options in the disabled sufferer. Since the primary etiology is suggested to be anal spasm, treatments that produce relaxation of the internal
anal sphincter have all been considered in the therapeutic armamentarium of proctalgia
fugax.
12,32
Unfortunately, there are few case series and fewer RCTs providing scientific evidence upon which to base management of these patients. In addition, most options were
reported as effective by a physician who first self-treated and then prescribed the same in a
few patients.
12,32
In case reports warm sit bath and digital anal dilatation where first suggested as effective means to achieve rapid sphincter relaxation, as well as a tap water
enema.
12
However, it has been noted that there is often insufficient time to undertake
any of these measures.
32
Oral calcium channel blockers such as nifedipine and diltiazem
have been shown to decrease anal sphincter pressure and are reported to be effective
treatments in small case series.
12,32
Topical nitroglycerin ointment has been reported to
be successful, but is not verified in an RCT.
32
Recently an RCT was performed in 18
Chapter 19 • Proctalgia and Other Anorectal Pain Syndromes 245
proctalgia fugax patients comparing inhaled salbutamol, a β-adrenergic agonist, to
placebo.
34
Salbutamol was more effective than placebo for shortening pain duration in
those patients where pain lasted longer than 20min, although this pain duration would
be suggestive of CP.
8
A potential beta agonist inhibition of anal sphincter tone was sug-
gested by a phys ician who self-treated.
34
Eventually, patients with severe and frequently
recurring proctalgia fugax symptoms will likely consult for surgery in an effort to solve the
problem. However, there is no evidence supporting invasive procedures, particularly
internal anal sphincterotomy
12,32
( Table 19.2).
19.4 Coccygodynia
Coccygodynia is defined as pain arising in or around the coccyx that is usually triggered by
prolonged sitting on hard surfaces.
13
The pain is considered chronic when it lasts for
>2months and it is commonly reported after repetitive trauma of different types and
Table 19.2 Treatment of Proctalgia Syndromes
Category Examples Indications
Level of
Evidence Comments
Muscle relaxant Digital massage of the
puborectalis muscle
Chronic
proctalgia/
proctalgia fugax
D/D No standardized methodology,
often provided with sitz bath
Muscle relaxant Diazepam Chronic
proctalgia/
proctalgia fugax
C/D Poorly effective in the long term,
addictive potential
Muscle relaxant Electrogalvanic
stimulation
Chronic
proctalgia
B More effective than Massage for
LAS, poorly effective in the long term
Anticholinergic Botulinum toxin A
intraanal injection
Chronic
proctalgia
D Poorly effective in small sized RCT
Antiinflammatory Pelvic floor muscles
steroid injection
Chronic
proctalgia
D Poorly effective in small sized RCT
Behavior therapy Biofeedback to
improve defecation
effort
Chronic
proctalgia
B Most effective treatment for LAS in
single RCT
Electrical
stimulation
Sacral nerve
neuromodulation
Chronic
proctalgia
D Conflicting results in open label trials
Ca-channel
blockers
Diltiazem, nifedipine Proctaglia fugax D Case series, potential side effects, no
long term follow-up
Organic nitrates Glyceryl trinitrate
ointment
Proctalgia fugax D Case reports, potential side effects
Beta-blockers Salbutamol Proctalgia fugax D Case series, no long term follow-up
Surgery Anal sphincterotomy Proctalgia fugax D Effectiveness limited to anal
myopathy
Abbreviations: RCT, randomized controlled trial.
Levels of evidence: A, metaanalysis of well-designed randomized controlled trials; B, at least one well-designed randomized controlled
trial; C, at least one well-designed observational study; D, case series.
246 ANORECTAL DISORDERS
childbirth.
12,13
Coccygodynia may be of idiopathic origin or secondar y to lumbar disc
degeneration.
12,13
Coccygodinia is also reported as a complication of epidural injection
of anesthetic, and various rectal and spine surgeries.
1
It is more common in women than
in men and obesity seems to act as a predisposing factor for the resulting pelvic rotation.
13
Chronic spasm of the pelvic floor exerting a painful tension on a stiff coccyx has been traditionally considered to be a relevant etiology with trauma acting as a trigger.
13
However,
instability of the coccyx in a high percentage of patients was then discovered by dedicated
X-ray examination.
35
Epidemiological data of coccygodynia in the general population are
lacking, but it is considered to be a rare disorder.
1
Diagnosis of coccygodynia relies heavily
on the history and clinical exam. Questioning the patient about previous trauma to the
coccyx or childbirth trauma is a must, since the absence of a previous trauma makes
the diagnosis unlikely.
35
Patients may report mild tenderness on puborectalis posterior
traction on DRE and occasionally a differential diagnosis of CP needs to be considered.
1,13
Instability of the coccyx on palpation is a coccygodinia supportive sign.35When performing dynamic X-ray, more than half of coccygodinia patients show features of coccyx instability, which correlates with pain severity.
13,35
The initial treatment of coccygodinia is focused on avoiding offending factors and
includes sitting on a donut-shaped pillow or a gel cushion to reduce pressure, posture
ameliorating interventions, warm sit bath, and analgesic drugs.
35
A recent prospective
RCT aimed to compare intrarectal pelvic-floor muscle manipulation (three sessions) versus placebo physiotherapy (sacral short-wave magnetic field applied at marginal power)
in 102 chronic coccygodinia patients.
36
Primary outcome was the subjective decrement of
>50% in pain intensity on a VAS at follow-up intervals of 1–6 months. At 1-month follow-
up 22% of patients in the manipulation group reported a significant pain decrement compared to only 12% of patients in the placebo group. Psychosocial factors seem to predict a
poor treatment outcome.
36
When coccygodynia is severe and unresponsive, surger y may be considered.1A recent
review on surgical treatment of coccygodynia reported on 24 studies but only two of them
were prospective.
37
Surgery was a treatment option in a minority of patients (approximately 19%), but mean satisfaction rate for pain relief was high (over 80% of treated
patients). The mean overall complication rate was 10.9% with wound infection being
the most commonly reported complication.
37
19.5 Pudendal Neuralgia
Pudendal neuralgia refers to a chronic perineal pain syndrome due to entrapment and
injury of the pudendal nerve in its muscolo-osteo-aponeurotic tunnel between the sacrotuberal and sacrospinal ligaments in the absence of organic diseases that may explain
symptom.
13,38
Pudendal neuralgia is also called Alcock’s canal syndrome, or pudendal
canal syndrome.
13,38
Burning sensation, numbness, or paresthesia in the gluteal, perineal,
and genital areas are also commonly reported in association with the pain.
38
Dyspareunia
and erectile dysfunction may also be reported by patients.
38
Chapter 19 • Proctalgia and Other Anorectal Pain Syndromes 247
Epidemiology of pudendal neuralgia in the general population is unknown, but it is
generally considered to be a rare disorder. The diagnosis is usually entertained in highly
focused pelvic-floor units. Particularly controversial is its association with rectal pain,
which will lead to differential diagnosis with CP.
13
In 2006 a multidisciplinary working
party on pudendal neuralgia was held in Nantes (France) and concluded that only the
operative finding of nerve entrapment and postoperative pain relief can formally confirm
the diagnosis, and then only provided the placebo effect of surgery is excluded.
7
However,
four domains to diagnose pudendal neuralgia have been defined, namely: (1) essential criteria,
2
complementary diagnostic criteria,3exclusion criteria, and4associated signs not
excluding the diagnosis. Essential criteria are particularly relevant and worth detailed
discussion:
(1) Pain should be limited to the innervation territory of the pudendal nerve. This
excludes any pain that is limited to the coccygeal, pelvic, or gluteal areas.
(2) Pain is predominantly experienced while sitting in accordance with the nerve-
compression etiology hypothesis. In long-standing pudendal neuralgia pain may
become continuous, but it is still worsened by the sitting position.
(3) The pain rarely awakens the patient at night and only transiently.
(4) On clinical exam no objective sensory impairment can be found even in the presense
of paresthesia.
(5) Pain should be relieved by anesthetic infiltration of the pudendal nerve. This essential
criterion is poorly specific, as any perineal pain may be relieved by pudendal nerve
block for anatomical reasons.
1,39
In the complementary diagnostic criteria are included the sensation of a rectal foreign
body and the worsening of pain during defecation. When diagnosed, pudendal neuralgia
is treated by pudendal nerve block that is both diagnostic and therapeutic.
7
However, data
on the long-term benefits of the procedure are lacking.
1
Competing Interests
Dr. Chiarioni is a member of the consulting/speaker Board of Aboca, Alfa-Sigma, Kyowa Kirin, Malesci,
Omeopiacenza, Takeda Italia, member of the Anorectal Committee of the Rome Foundation and of the
International Anorectal PhysiologyWorking Group. Dr. Carestiato has no conflict of interest to disclose.
References
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4. Thaysen EH. Proctalgia fugax. Lancet. 1935;2:243–246.
248 ANORECTAL DISORDERS
5. Thiele GH. Tonic spasm of the levator ani, coccygeus, and piriform muscle: relationship to coccygo-
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6. Smith WT. Levator syndrome. Minn Med. 1959;42:1076.
7. Labat JJ, Riant T, Robert R, Amarenco G, Lefaucheur JP, Rigaud J. Diagnostic criteria for pudendal neu-
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8. Rao SSC, Bharucha AE, Chiarioni G, et al. Anorectal disorders. Gastroenterology. 2016;150:1430–1442.
9. Drossman DA, Li Z, Andruzzi E, et al. U.S. householder survey of functional gastrointestinal disorders:
prevalence, sociodemography and health impact. Dig Dis Sci. 1993;38:1569–1580.
10. Palsson OS, Whitehead WE, van Tilburg MAL, et al. Development and validation of the Rome IV diag-
nostic questionnaire for adults. Gastroenterology. 2016;150:1481–1491.
11. Adams K, Gregory WT, Osmundsen B, Clark A. Levator myalgia: why bother. Int Urogynecol J.
2013;24:1687–1693.
12. Andromanakos NP, Kouraklis G, Alkiviadis K. Chronic perineal pain: current pathophysiological
aspects, diagnostic approaches and treatment. Eur J Gastroenterol Hepatol. 2011;23:2–7.
13. Mazza L, Formento E, Fronda G. Anorectal and perineal pain: new pathophysiological hypothesis.
Tech Coloproctol. 2004;8:77–83.
14. Park DH, Yoon SG, Kim UK, et al. Comparison study between electrogalvanic stimulation and local
injection therapy in levatorani syndrome. Int J Color Dis. 2005;20:272–276.
15. Gilliland R, Heymen JS, Altomare DF, Vickers D, Wexner SD. Biofeedback for intractable rectal pain:
outcome and predictors of success. Dis Colon Rectum. 1997;40:190–196.
16. Raahave D. Chronic proctalgia from leg length discrepancy relieved by a shoe insole. J Gastrointest Dig
Syst. 2015;5:292.
17. Salvati EP. The levator syndrome and its variant. Gastroenterol Clin N Am. 1987;16:71–78.
18. Renzi C, Pescatori M. Psychologic aspects in proctalgia. Dis Colon Rectum. 2000;43:535–539.
19. Christiansen J, Bruun E, Skjoldbye B, Hagen K. Chronic idiopathic anal pain: analysis of ultrasonog-
raphy, pathology, and treatment. Dis Colon Rectum. 2001;44:661–665.
20. Hompes R, Jones OM, Cunningham C, Lindsey I. What causes chronic idiopathic perineal pain? Colo-
rectal Dis. 2011;13:1035–1039.
21. Chiarioni G,
Nardo A, Vantini I, Romito A, Whitehead WE. Biofeedback is superior to electrogalvanic
stimulation and massage for treatment of levatorani syndrome. Gastroenterology.
2010;138:1321–1329.
22. Hull TL, Milsom JW, Church J, Oakley J, Lavery I, Fazio V. Electrogalvanic stimulation for levator syn-
drome: how effective is in the long-term? Dis Colon Rectum. 1993;36:731–733.
23. Chiarioni G, Kim SM, Vantini I, Whitehead WE. Validation of the balloon evacuation test: reproduc-
ibility and agreement with findings from anorectal manometry and electromyography. Clin Gastroen-
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25. Sohn N, Weinstein MA, Robbins RD. The levator syndrome and its treatment with high-voltage elec-
trogalvanic stimulation. Am J Surg. 1982;144:580–582.
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27. Grimaud JC, Bouvier M, Naudy B, Guien C, Salducci J. Manometric and radiologic investigations and
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28. Chiarioni G. Biofeedback treatment of chronic constipation: myths and misconceptions. Tech Colo-
proctol. 2016;20:611–618.
Chapter 19 • Proctalgia and Other Anorectal Pain Syndromes 249
29. Falletto E, Masin A, Lolli P, et al. Is sacral nerve stimulation an effective treatment for chronic idio-
pathic anal pain. Dis Colon Rectum. 2009;52:456–462.
30. Dudding TC, Thomas GP, Hollingshead JR, George AT, Stern J, Vaizey CJ. Sacral nerve stimulation: an
effective treatment for chronic functional anal pain? Colorectal Dis. 2013;15:1140–1144.
31. Takano M. Proctalgia fugax: caused by pudendal neuropathy? Dis Colon Rectum. 2005;48:114–120.
32. Kamm MA, Hoyle CH, Burleigh DE, et al. Hereditary internal anal sphincter myopathy causing proc-
talgia fugax and constipation. A newly identified condition. Gastroenterology. 1991;100:805–810.
33. Jeyarajah S, Chow A, Ziprin P, Tilney H, Purkayastha S. Proctalgia fugax, an evidence-based manage-
ment pathway. Int J Colorectal Dis. 2010;25:1037–1046.
34. de Paredes V, Etiennev I, Bauer P, Taouk M, Atienza P. Proctalgia fugax: demographic and clinical char-
acteristics, what every doctor should know from a prospective study of 54 patients. Dis Colon Rectum.
2006;50:893–989.
35. Eckardt VF, Dodt O, Kanzler G, Bernhard G. Treatment of proctalgia fugax with salbutamol inhalation.
Am J Gastroenterol. 1996;91:686–689.
36. Traycoff RB, Crayton H, Dodson R. Sacrococcygeal pain syndromes: diagnosis and treatment. Ortho-
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37. Maigne JY, Chatellier G, Faou ML, Archambeau M. The treatment of chronic coccydynia with intrar-
ectal manipulation: a randomized controlled study. Spine. 2006;31:E621–E627.
38. Karadimas EJ, Trypsiannis G, Giannoudis PV. Surgical treatment of coccygodynia: an analytic review of
the literature. Eur Spine J. 2011;20:698–705.
39. Benson JT, Griffis K. Pudendal neuralgia, a severe pain syndrome. Am J Obstet Gynecol.
2005;192:1663–1668.
Further Reading
40.
Robert R, Prat-Pradal D, Labat JJ, et al. Anatomic basis of chronic perineal pain: role of the pudendal
nerve. Surg Radiol Anat. 1998;20:93–98.
250 ANORECTAL DISORDERS
20
Postsurgical Anorectal Disorders
Donato F. Altomare
*,†, Arcangelo Picciariello*
,†
* DE P T O F E M E R GEN C Y AND O R G A N T R A NSP L A N T ATI O N & IN T E R D EP A R T M E NT A L R ESE A R C H
CENT E R F O R P E L VIC F L O OR D I S EAS E S (C IR P A P ) , U N I V ERS I T Y “ALD O M ORO ” O F B A R I ,
BAR I , IT ALY
†
AZI E N D A OSP E D A L IE R O - U NIV E R S ITA R I A POLI C L I NIC O B ARI , B ARI , I TAL Y
20.1 Introduction
Surgeries on the anus are among the most frequent surgical procedures, often relegated to
young surgical residents and late in the evening at the end of the operating list. Nevertheless, this kind of surgery deserves careful attention since inadequate procedu res may often
affect anal function, such as the control of defecation, with severe impact on a patient’s
quality of life.
20.2 Functional Disorders After Surgery for Anorectal
Diseases
20.2.1 Hemorrhoids
Surgery for hemorrhoids is the most frequent proctological operation and several types of
operation have been proposed to minimize postoperative anal pain and reduce the
recurrence rate.
The most commonly performed operation is still the Milligan-Morgan technique
described by these two authors in 1936
1
and nowadays performed using more sophisticated devices like ultrasound (Ultracision, Johnson & Johnson) or radiofrequency
(Ligasure, Covidien-Medtronic) forceps. This operation involves the removal of the prolapsing hemorrhoids leaving the wounded anoderm to heal spontaneously within
3–4weeks. The variant proposed by Ferguson,
2
frequently adopted in the US, includes
the closure of the remnant mucosa with resorbable sutures in order to minimize postoperative pain and favor healing.
A few technical details need to be respected in this operation, namely to spare adequate
mucosal bridges between the resected hemorrhoidal prolapse and to save the internal
anal sphincter during the removal of the mucosa and submucosa containing the hemorrhoidal vessels. Failure to stick to these simple but pivotal recommendations may lead to
anal stricture (because of a circular scar) (
Fig. 20.1) or anal incontinence, respectively.
Anorectal Disorders. https://doi.org/10.1016/B978-0-12-815346-8.00020-5
© 2019 Elsevier Inc. All rights reserved.
251
Anal stricture is responsible for a severe difficulty in defecation because of the narrow
and inelastic passage through the anal canal. This functional disorder may severely affect
the quality of life of these patients.
Another common operation for hemorrhoids is the stapled hemorrhoidopexy,
3
which
involves the resection of a cylinder of rectal mucosa at least 4cm from the dentate line and
a mucosal anastomosis by a 33mm circular stapler (PPH stapler, Ethicon EndoSurgery—
Cincinnati Ohio, United States). This will result in pexy of the hemorrhoid prolapse and
spares the sensitive anoderm.
4
Consequently, the operative results should be “painless.”
This new surgery has determined several new potential complications that are not easy
to manage. Most of these result from the incorrect execut ion of the procedure, although
sometimes the occurrence of complications is unpreventable. The most common functional disturbance caused by this operation is urge fecal incontinence, which in most
cases improves spontaneously in a few months, but sometimes is persistent.
5
Anal or rectal pain is another frequent functional consequence because the stapled suture involves
the sensitive epithelium of the anoderm or terminal branches of the pudendal nerves.
6
Other patients operated by stapled hemorrhoidopexy complai n of obstructed defecation. The reason for this is rarely a stricture of the anastomosis and more frequently is an
internal mucosal prolapse (intussusception) that has passed undetected only becoming
clinically evident when there is a circular scar at the level of the anorectal junction.
7
In
a few cases a too high placement of the stapled suture may cause an hourglass deformity
of the rectum, while the wrong placement of the circular mucosa suture before the firing of
the staple can create the “pocket syndrome”
7
(Fig. 20.2). This new disease is characterized
by an unpleasant anal sensation, difficulty in evacuation, and sometimes pain due to the
formation of a marsupial-like pocket in the anterior rectal wall.
FIG. 20.1 Severe anal stricture following a Milligan-Morgan operation.
252 ANORECTAL DISORDERS
20.2.2 Anal Fissure
Anal fissure is one of the most frequent and painful anal diseases, which is usually treated
conservatively by muscle relaxant and stool softeners; however, anal fissures resistant to
conservative treatment undergo lateral internal sphincterotomy.
8
This operation has been
suggested to involve the potential risk for minor anal incontinence.
9
20.2.3 Anal Fistulas
Cryptoglandular and Crohn’s diseases related anal fistulas are common but often challenging anal diseases, particularly complex transsphincteric fistulas, horseshoes, and
recurrent fistulas. In female patients, where the external sphincter is short, the risk of anal
incontinence is very high. Anal deformity (key hole deformity) (
Fig. 20.3 ) is often the result
of an extended fistulotomy. Other treatments with the potential for damage to continence
are core-out fistulectomy and skin/mucosal flaps. In recent years several other minimally
invasive treatments have been proposed with the aim to minimize this risk.
20.2.4 Obstructed Defecation Syndrome
Evacuation difficulties are a common complaint, mainly in female patients. The most frequent causes are nonemptying rectocele, rectoanal intussusception, and perineal descent,
often associated in the same patient (
Fig. 20.4).
FIG. 20.2 Magnetic resonance defecography showing a nonemptying posterolateral pseudodiverticulum of the
rectum. Courtesy of dr Vittorio Piloni.
Chapter 20 • Postsurgical Anorectal Disorders 253
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