Investigation for method of observing major muscle groups of levator ani in female by transvaginal two‐dimensional sonography / 中华超声影像学杂志

To evaluate and discuss feasibility and value of the transvaginal two‐dimensional sonography in distinguishing the major muscle groups of levator ani ,including puborectalis and iliococcygeus ,by observing the morphology and contraction form of these muscles . Methods Total of 145 nulliparous women were chosen . T he major muscle groups of levator ani were observed by transvaginal two‐dimensional sonography . T he images of puborectalis and iliococcygeus were obtained both at rest and contracting . T he features of the sonogram and the direction of muscle contraction were summarized . T he consistency between two sonographers was analyzed by ICC . Results T ransvaginal two‐dimensional sonography could be used to observe and distinguish the major muscle groups of levator ani . Puborectalis was showed distinctly as thick and uniform hyperechoic linear zone . Iliococcygeus was showed as triangle zone with sparse hyperechoic lines ,with one angle pointing to the caudal .During contracting ,puborectalis moved from the dorsal to the ventral while iliococcygeus contracted from the caudal to the cephalic . T he consistency between two sonographers for distinguishing the morphology and contraction form between the puborectalis( ICC＝0 .93 ,0 .89 ) and ilococcygeus ( ICC＝0 .78 ,0 .75 ) were remarkably high . Conclusions T ransvaginal two‐dimensional sonography could be used to observe dynamically and distinguish the morphology and contraction form of the levator ani muscles ,including puborectalis and iliococcygeus . It is a convenient and reproducible method to help study mechanism of levator ani injury and provide fine radiological evidence of making individual treatment .

Morphological characteristic of anal canal in patients with dyssynergic defecation and its correlation with anorectal manometry / 中华胃肠外科杂志

Objective@#To evaluate the diagnostic value of three-dimensional endoanal ultrasound (3D-EAUS) for dyssynergic defecation (DD).@*Methods@#A case-control study was performed to retrospectively collectclinical data of 46 DD patients, including 16 males and 30 females with median age of 51 (20 to 70) years, at Nanjing Hospital of Chinese Medicine from February 2012 to April 2015.All the patients met the diagnostic criteria of functional constipation of Rome III. The paradoxical contraction of puborectalis (PR) muscle was found by both rectal examination and anorectal manometry. In the same period,45 healthy volunteers, including 22 males and 23 females with median age of 48 (21 to 72) years, without pelvic operation history, and with normal defecation in recent 6 months, were enrolled as the control group. No significant differences were observed in age and gender between two groups (both P>0.05). Cleveland constipation score of DD group was higher than that of control group [15(8-24) vs. 5(1-9), t=15.720, P<0.001]. 3D-EAUS examination was performed in all the subjects. Thickness and length of internal anal sphincter (IAS) (anterior side and posterior side), thickness of PR muscle, length of external anal sphincter (EAS) plus PR muscle, and puborectalis angle were measured and compared by using student t test between two groups. Correlation between these ultrasound parameters and anorectal manometry was examined by Pearson correlation analysis.@*Results@#Both male and female in the DD group had the greater thickness of IAS, as compared to those in the control group [male: (1.7±0.5) mm vs.(1.5±0.2) mm, t=2.516, P=0.016; female: (1.9±0.4) mm vs.(1.6±0.5) mm, t=2.034,P=0.047]. No significant differences between the two groups were observed with respect to the posterior length of IAS, length of EAS plus PR muscle, and thickness of PR muscle (all P>0.05). Compared to the control group, male in the DD group had smaller puborectalis angle during straining [(87.0±3.6)° vs. (90.5±1.8)°,t=3.502,P=0.002];female in the DD group had smaller puborectalis angle both in resting and straining [resting:(86.5±3.8)° vs. (90.1±2.1)°,t=4.047, P<0.001;straining: (84.1±4.5)° vs. (90.2±2.3)°, t=5.938, P<0.001]. Correlation analysis showed that anterior length of IAS was positively correlated with anal resting pressure (r=0.321, P=0.030); the length of EAS plus PR muscle was positively correlated with anal squeeze pressure (r=0.415, P=0.004). There were no correlations between the thickness and the posterior length of IAS and the anal resting pressure, or between the thickness of PR muscle and the anal squeeze pressure (all P>0.05).@*Conclusions@#The 3D-EAUS can accurately assess the morphological features of anal canal in DD patients. There is a certain positive correlation between 3D-EAUS and anorectal manometry.

Efectos del Antecedente de Abuso, Rumiación, Ansiedad y Depresión Sobre la Contracción Paradójica del Puborrectal / Effects of Abuse History, Rumination, Anxiety, and Depression on the Paradoxical Contraction of the Puborectalis Muscle / Efeitos do Antecedente de Abuso, Ruminação, Ansiedade e Depressão sobre a Contração Paradoxal do Puborretal

Resumen El objetivo de este trabajo fue determinar los efectos del antecedente de abuso sexual y emocional, rumiación, ansiedad y depresión sobre la contracción paradójica del puborrectal. Se realizó un estudio de campo con diseño transversal en 118 pacientes. Los resultados de los análisis de regresión demuestran que el antecedente de abuso sexual predice contracción paradójica del puborrectal, depresión y rumiación, además de ejercer efecto indirecto sobre depresión y ansiedad a través de rumiación. El antecedente de abuso emocional predice mayor ansiedad y menor depresión. La rumiación predice ansiedad y depresión. Se sugiere aplicar estos resultados en la práctica y explorar en estudios ulteriores las interrogantes derivadas de este trabajo.

Abstract The objective of this research was to determine the effects of sexual and emotional abuse history, rumination, anxiety, and depression on the paradoxical contraction of the puborectalis muscle. A cross-sectional study was carried out in 118 patients. The results of regression analyses show that a history of sexual abuse predicts paradoxical contraction of the puborectalis muscle, depression, and rumination, besides having an indirect effect on depression and anxiety through rumination. A history of emotional abuse predicts greater anxiety and less depression. The article suggests that these results must be applied in practice and that subsequent studies should explore the questions deriving from this research.

Resumo O objetivo deste trabalho foi determinar os efeitos do antecedente de abuso sexual e emocional, ruminação, ansiedade e depressão sobre a contração paradoxal do puborretal. Realizou-se um estudo de campo com desenho transversal em 118 pacientes. Os resultados das análises de regressão demonstram que o antecedente de abuso sexual prevê a contração paradoxal do puborretal, depressão e ruminação, além de exercer efeito indireto sobre depressão e ansiedade através da ruminação. O antecedente de abuso emocional prevê maior ansiedade e menor depressão. A ruminação prevê ansiedade e depressão. Sugere-se aplicar esses resultados na prática e explorar as interrogantes derivadas deste trabalho em estudos posteriores.

Transperineal three-dimensional ultrasonographic evaluation on effect of pregnancy and delivery on female anal sphincter complex / 中国医学影像技术

Objective To explore the effects of pregnancy and delivery on the anal sphincter complex (ASC) with 3D-US imaging technique.Methods Transperineal 3D-US images were obtained in 131 women,including 15 nulliparous women (nulliparous group),31 women in middle pregnancy (middle pregnancy group),31 women in late pregnancy (late pregnancy group),24 underwent cesarean section (cesarean section group) and 30 underwent natural childbirth (natural childbirth group).In the resting and anal shrinking state,external anal sphincter (EAS) thickness was measured at 3,6,9 and 12 o'clock positions at distal plane,internal anal sphincter (IAS) thickness was measured at the same four positions at proximal,middle and distal planes,and at the 4 and 8 o'clock positions,the bilateral puborectails muscle (PRM) at middle plane were measured.Results In resting state,at 12 and 9 o'clock positions on the proximal plane,and 3 and 9 o'clock positions on middle plane,the thickness of IAS of cesarean section group was thicker than those in nulliparous group and natural childbirth group (all P＜0.05).On the distal plane,the thickness of EAS at 4 positions of caesarean section group and the natural childbirth group was thinner than those in the late pregnancy group (all P＜0.05).In anal shrinking state,the thickness of IAS at 12 and 9 o'clock positions on the proximal plane,and the thickness of EAS 12 o'clock position on the distal plane,which later pregnancy and cesarean section group were thicker than those in natural children group (all P＜0.05).In resting and anal shrinking state,the thickness of left and right PRM in natural childbirth group were thinner than those in late pregnancy group and cesarean section group (all P＜0.05).In resting and anal shrinking state of nulliparous group,anal shrinking state of middle pregnancy group,and resting state of late pregnancy group,the thickness of left PRM was thicker than those of right PRM (all P＜0.05).Conclusion ASC changes occur in varying degrees in women in middle pregnancy and [ate pregnancy,also in women after cesarean section and natural childbirth.ASC thickening is a protective mechanism for women during pregnancy.

Quantitative evaluation on puborectalis function in patients with pelvic organ prolapse using shear wave elastography / 中国医学影像技术

Objective To evaluate the contraction function of puborectalis (PR) with shear wave elastography (SWE).Methods Twenty-eight patients with pelvic organ prolapse (POP-Q Ⅲ group and POP-Q Ⅳ group,each n=14) and 28 healthy volunteers (control group) were enrolled.The Young's modulus of PR in the front,middle and back of pubic rectal muscles of each group at resting and maximal rectal state were measured with shear wave elastography,and then were statistically analyzed.Results Youngs modulus of maximum rectal state of each group was higher than that of resting state (all P＜0.05).At resting and maximal rectal state,the Young's modulus and their differences in POP-Q Ⅲ group and POP-Q Ⅳ group were significantly different compared with control group (all P＜0.05),but those in POP-Q Ⅲ group and POP-Q Ⅳ group were not (all P＞0.05).Conclusion Decrease of PR systolic function can be observed in patients with pelvic organ prolapse,and SWE can be used to detect abnormal function of PR systolic function.

Dyschesia and changes of pubo-rectal angle as observed by 3D ultrasound / 中华普通外科杂志

Objective To discuss the relativity of dyschesia with the change of puborectalismuscle.Methods 68 patients with dyschesia were compared with 68 healthy volunteers at lithotomy position undergoing 3D ultrasonography on resting,contracting and maximum exertion phase respectively.Three dimensionally reconstructed images were reconstructed and pubo-rectal angle and the thickness of puborectalis muscle at 6 o'clock position were measured.Results The pubo-rectal angle of the study group and control group had no significant differences at either resting [(86 ± 8) ° vs.(86 ± 8)°] or contracting phases [(88 ± 9) ° vs.(86 ± 7) °] (t =-0.145,t =0.434,P ＞ 0.05).While at maximum exertion the differences were significant [(80 ± 6) °vs.(95 ± 5) °,t =-5.397,P ＜ 0.05].The d-value of pubo-rectal angle between maximum and resting exertion statistically different [(6 ± 3) °,(-9 ± 7) °,t =5.551,P ＜ 0.05].The thickness of puborectalis muscle between the two groups differed statistically significant only at maximum exertion phase [(4.60 ± 0.60) mm vs.(3.97 ± 0.32) mm,t =6.872,P ＜ 0.05].The d-value of the thickness of puborectalis muscle between maximum and resting exertion were statistically different (t =-11.474,P ＜ 0.05).Conclusions The pubo-rectal angle of the study group is smaller at maximum exertion than the control group.The thickness of puborectalis muscle at six o'clock (lithotomy position) in study group is larger at maximum exertion than the control group.And the severity of constipation changed with the variation of angle.

Assessment of the influencesof different delivery methods of contractibility of the puborectalis in postpartum women by pelvic ultrasound / 中华医学超声杂志（电子版）

Objective To assess the recovery of contraction function ofpuborectalis (PR) in women at different periods after delivery with different delivery modes,and to discuss the effect of delivery mode on PR contraction.Methods Between September 2016 and December 2016,168 primiparas who underwent ultrasound examination at the First Affiliated Hospital of Shenzhen University were enrolled.All participants were able to accomplish Valsalva maneuver.Participants were divided into two groups according to delivery modes:the vaginal delivery group and the cesarean section group.This two groups were further divided into three groups according to their periods after delivery:42-60 days after delivery (group l),61-90 days after delivery (group 2) and more than 90 days after delivery (group 3).Two dimensional translabial ultrasound examination were performed in all participants both at rest and in maximal contraction status.Thickness of anterior,middle and posterior parts of PR were measured and thickening rate was calculated.Data were evaluated by t-test and comparisons were made between the vaginal delivery groups and cesarean section groups,respectively.Results In the vaginal delivery group 1,the thickening rate of the anterior,middle and posterior parts of right-side PR were (35.57 ± 19.80)％,(31.46 ± 20.96)％ and (24.18 ± 21.51)％,while the thickening rate of left-side PR were (25.23 ± 14.36)％,(21.25 ± 13.79)％ and (20.60± 11.58)％,respectively.In the cesarean section group 1,the thickening rate of the anterior,middle and posterior parts of right-side PR were (30.27± 19.22)％,(29.50± 17.21)％ and (28.25± 14.92)％,while the thickening rate of left-side PR were (33.02± 20.65)％,(30.56± 20.11)％ and (28.64± 14.84)％,respectively.In the vaginal delivery group 2,the thickening rate of the anterior,middle and posterior parts of right-side PR were (29.62t 16.93)％,(24.94± 14.56)％ and (19.26± 11.12)％,while the thickening rate of left-side PR were (20.17±15.70)％,(19.95± 13.07)％ and (22.19± 14.50)％,respectively.In the cesarean section group 2,the thickening rate of the anterior,middle and posterior parts of right-side PR were (30.82± 15.65)％,(17.70± 10.34)％and (19.30± 7.02)％,while the thickening rate of left-side PR were (18.33± 1 1.61)％,(16.46 ± 10.51)％and (16.62± 1 1.69)％,respectively.In the vaginal delivery group 3,the thickening rate of the anterior,middle and posterior parts of right-side PR were (33.56 ±19.79)％,(25.18 ±11.80)％ and (17.44± 11.41)％,while the thickening rate of left-side PR were (28.06± 10.93)％,(22.25 ± 11.82)％ and (22.15 ± 12.69)％,respectively.In the cesarean section group 3,the thickening rate of the anterior,middle and posterior parts of right-side PR were (46.36± 20.65)％,(17.00 ± 10.34)％ and (10.86±3.40)％,while the thickening rate of left-side PR were (22.54± 13.81)％,(13.90± 10.51)％ and (18.24± 11.17)％,respectively.There were no statistically difference of the thickening rate of PR in both side between the vaginal delivery subgroups and the cesarean section subgroups (For group 1,right side:t=0.87,P=0.34;t=0.32,P=0.75;t=0.68,P=0.50;left side:t=1.48,P=0.15;t=1.82,P=0.08;t=1.36,P=0.12.For group 2,right side:t=0.22,P=0.83;t=1.64,P=0.11;t=0.01,P=0.99;left side:t=0.43,P=0.67;t=0.79,P=0.44;t=1.13,P=0.27.For group 3,right side:t=0.73,P=0.48;t=1.22,P=0.23;t=0.868,P=0.40.left side:t=0.89,P=0.41;t=1.79,P=0.89;t=0.79,P=0.44).Conclusion There was no significant differences between the impact of two delivery modes on the contraction function of the PR,and the protective effect of caesarean section on the contraction function of the PR was limited.

Length Tension Function of Puborectalis Muscle: Implications for the Treatment of Fecal Incontinence and Pelvic Floor Disorders

BACKGROUND/AIMS: External anal sphincter (EAS) and puborectalis muscle (PRM) play important role in anal continence function. Based on length-tension measurement, we recently reported that the human EAS muscle operates at short sarcomere length under physiological conditions. Goal of our study was to determine if PRM also operates at the short sarcomere length. METHODS: Length-tension relationship of the PRM muscle was studied in vivo in 10 healthy nullipara women. Length was altered by vaginal distension using custom-designed probes of 5, 10, 15, 20, 25 and 30 mm diameters as well as by distending a polyethylene bag with different volumes of water. Probes were equipped with a reverse perfuse sleeve sensor to measure vaginal pressure (surrogate of PRM tension). PRM electromyogram (EMG) was recorded using wire electrodes. Three-dimensional ultra-sound images were obtained to determine effect of vaginal distension on PRM length. RESULTS: Ultrasound images demonstrate distension volume dependent increase in PRM length. Rest and squeeze pressures of vaginal bag increased with the increase in bag volume. Similarly, the change in vaginal pressure, which represents the PRM contraction increased with the increase in the probe size. Increase in probe size was not associated with an increase in EMG activity (a marker of neural drive) of the PRM. CONCLUSIONS: Probe size dependent increase in PRM contraction pressure, in the presence of constant EMG (neural input) proves that the human PRM operates at short sarcomere length. Surgically adjusting the PRM length may represent a novel strategy to improve treat anal continence and possibly other pelvic floor disorders.

Preliminary study of endoluminal two-dimensional ultrasonography to evaluate puborectalis muscle of nulliparous women / 中华超声影像学杂志

Objective To investigate the measurement standards and clinical application of observing anatomical morphologies and contractile function of puborectalis muscle on pelvic floor parasagittal plane by endoluminal two-dimensional ultrasonography.Methods The thickness and thickening rate of puborectalis muscle of 78 young nulliparous women were measured on pelvic floor parasagittal plane at three levelsurethral level (anterior),vaginal level (central) and rectal level (posterior),both at rest and during contraction.And the thickening rates of these parts during contraction were compared with each other.Interclass correlation coefficients were calculated to evaluate the consistency of the datas.Results At rest,thickness of anterior part of the left was (9.23 ± 0.20)mm,and that of the right was (8.99 ± 0.20)mm.During contraction,thickness of anterior parts of bilateral puborectalis muscle were significantly thicker than that of central or posterior parts (P ＜0.05).The interclass coefficients were more than 0.93 and 0.83.Conclusions The endoluminal two-dimensional ultrasonography can be used to observe morphologies and contractile function dynamically of puborectalis on pelvic floor parasagittal plane.It is simple,reproducible and worthy of clinical promotion.

A preliminary application of levator-urethra gap in evaluating levtor avulsion in postpartum women / 中华超声影像学杂志

Objective To study the change of levator urethra gap(LUG) in postpartum female using pelvic floor three-dimensional ultrasonography.Methods Totally 80 postpartum women and 30 nulliparas were examined by three-dimensional pelvic floor ultrasonography.The images were obtained at maximal pelvic floor muscle contraction,and then the morphology of puborectalis muscle on tomographic ultrasound imaging were observed and the right LUG and left LUG were measured.Results The puborectalis was intact in all nulliparas and 69 postpartum women.The puborectalis avulsion was find in 11 postpartum women.The LUG of postpartum group was greater than that of nullipara group (P ＜0.05).In postpartum group,the LUG of puborectalis avulsion was greater than that of intact puborectalis(P ＜0.05).There was no difference between the right LUG and left LUG in nullipara group and in the postpartum women with intact puborectalis (P ＞ 0.05).ConcIusions LUG is a good imaging parameter to evaluate the levator avulsion in postpartum women.

Comparison of normal male puborectalis by ultrasound and magnetic resonance imaging / 中华超声影像学杂志

Objective To afford an new effective imaging technique for the morphological observation of the normal male pelvic floor by observing the normal male puborectalis with transrectal ultrasound and magnetic resonance imaging (MRI). Methods Thirty-six normal males were examined by transrectal ultrasound and MRI,data of puborectalis were recorded and compared including starting point, end point,appearance, structure, thickness and the relationship with peripheral organs. Results The results including the appearance,direction and internal echo of puborectalis and the relationship with peripheral organs can be clearly displayed by transrectal ultrasound compared with MRI. The thickness of right and left puborectalis at rest measured in ultrasound and in MRI were (6.22±0.57)mm, (6.19±0.59) mm, (6.20±0.61) mm and (6.17±0.53) mm, respectively. The thickness by two methods and two sides had no significant differences (P>0.05). The thickness of puborectalis measured by two methods did not correlate with age,height,body weight,the volume of prostate and interspinal diameter respectively. Conclusions Transrectal ultrasound is a new imaging method to observe male puborectalis. Identification for nomal puborectalis sonography is the foundation of diagnosis pelvic floor disease.

The Clinical Characteristics and Outcomes of Biofeedback Treatment for Patients with Nonrelaxing Puborectalis Syndrome

PURPOSE: Biofeedback treatment is thought to be appropriate for patients with nonrelaxing puborectalis syndrome (NRPR). The aim of this study is to analyze the physiologic characteristics and to assess the outcomes of biofeedback treatment for patients with NRPR. METHODS: Forty-six (46) patients with NRPR were evaluated with anorectal physiologic studies, including colonic transit time (n=26), anorectal manometry (n=41), defecography (n=46), anal sphincter EMG (n=28), and colonoscopy or barium enema (n=33). The treatment consisted of a training program with EMG-based biofeedback for 30 minutes once a week and routine supportive care, including Kegel practice. RESULTS: The mean age was 52.8 years, and the sex ratio was 1 male to 0.6 female. A delayed colonic transit time was noted in 5 patients (19.26%). In the NRPR group, the maximal voluntary contraction and the mean squeezing pressure were higher than they were for other patients with pelvic outlet obstructive disease. Also, the perineal descents and the dynamic change of anorectal angle were shorter. Polyps were observed in 6 patients (18.2%), melanosis coli in 4 patients (12.1%), and diverticula in 3 patients (9.1%). The rectoanal inhibitory reflex (RAIR) was negative in 3 patients (7.3%). The patients underwent a mean of 4.0 sessions, and the mean follow-up was 7.4 months. Twenty-three (23) patients (82.1%) experienced improved of symptoms or EMG findings. The patients (17.9%) who did not improve had several abnormal findings: neuro-psychologic disease with delayed colonic transit time in 2 cases, negative RAIR in 2 cases, and melanosis coli in one case. CONCLUSIONS: We think that biofeedback training is an effective treatment for patients with NRPR. In addition, several factors, such as neuro-psychologic diseases, delayed colonic transit time, negative RAIR, or melanosis coli may influence the prognosis for biofeedback treatment, so further large-scaled studies will be needed to confirm these findings.

The Clinical and Physiologic Characteristics of Patients with Pelvic Outlet Obstructive Disease

PURPOSE: With recent anorectal physiologic studies, functional etiologies of pelvic outlet obstructive disease were evaluated in detail. The current study was designed to assess the clinical and the physiologic characteristics of patients with pelvic outlet obstructive disease. METHODS: one hundred two (102) patients with pelvic outlet obstructive disease were evaluated with anorectal physiologic studies, including the colonic transit time (n=66), anorectal manometry (n=88), defecography (n=102), anal sphincter EMG (n=50), and colonoscopy or barium enema (n=77). The patients were categorized as group I (nonrelaxing puborectalis syndrome), group II (rectocele), group III (sigmoidocele), and group IV (rectoanal intussusception). The clinical and the physiologic characteristics were compared between the groups. RESULTS: The mean age was 51.9 years, and the sex ratio was 1:1.9. the populations of the groups were group I 45.1% (n=46), group II 36.3% (n=37), group III 5.9% (n=6), and group IV 9.8% (n=10). In group II and group III, co-existing etiologies were more, and the incidences of female patients was higher (P<0.05). Delayed colonic transit time was noted in 11 patients (17%). Diverticula was observed in 6 patients (8%), polyps in 12 patients (16%), and melanosis coli in 14 patients (18%). On anorectal manometry, group I showed higher maximal voluntary contraction and mean squeezing pressure than the other groups (P<0.05). On defecography, group I had a shorter perineal descent at rest and a smaller anorectal angle at push (P<0.05). CONCLUSIONS: The current study showed the clinical and the physiologic characteristics of the each functional etiology in patients with pelvic outlet obstructive disease. These results provide fundamental data for diagnosis of and tailored therapy for pelvic outlet obstructive disease.

Investigation of Defecographic Findings in Patients with Pelvic Outlet Obstructive Disease

PURPOSE: Defecography is a dynamic investigation which can influence clinical decision making in patients with pelvic outlet obstructive disease (POOD). The current study was designed to establish defecographic findings in patients with POOD. Specifically, we sought to assess the physiologic characteristics of categorized types by using anorectal physiologic tests. METHODS: One hundred seven patients (disease group; 45 men, 62 women) with POOD were retrospectively categorized as type I [non-relaxation of puborectalis (NRPR) only, n=19], type II [NRPR and rectocele, n=20], type III [NRPR, rectocele, and dynamic perineal descent (PD), n=17], type IV [deformed rectocele, mild-to-moderate fixed PD, and absence of NRPR, n=29], and type V [rectocele, severe fixed PD, and absence of NRPR, n=20] on the bases of defecographic findings. The ability to evacuate, the frequency/degree of intarectal intussusception (IRI), and the size of the rectocele were evaulated in these defecographic types of POOD. Age, duration of symptoms, and the physiologic findings of anal manometry and EMG/PNTML were compared for the five types. Eighteen healthy volunteers who had no defecation difficulty were used to estimate the normal findings of defecography. RESULTS: The age and the sex showed no significant differences among the types. The duration of symptoms was gradually lengthened from type I to V (P<0.01). The ability to evacuate in patients with POOD was significantly worse (failed to effectively evacuate) compared to that in the healthy volunteers (P<0.01). The frequency of IRI was increased more and more from type I to V (P<0.01). The size of the rectocele was significantly increased in types V compared to the other types (P<0.01). Manometric and neurologic findings, including EMG/PNTML, revealed no significant differences among the types. CONCLUSIONS: Even though there were no specific differences in the findings of the anal manometric and neurologic tests, the evacuation dynamics; were different in the five defecographic categories of patients with POOD. Specifically, these differences were relevants to the presence of NRPR, rectoceles, IRI, and perineal descent.

Role of Anorectal Physiologic Studies for the Diagnosis and Treatment of Non- relaxing Puborectalis Syndrome

PURPOSE: To assess the effectiveness of cinedefecography (CD), anal electromyography (EMG), and anal manometry (ARM) for the diagnosis of non-relaxing puborectalis syndrome (NRPR) and to compare the outcomes for patients after biofeedback therapy (BF). METHODS: The clinical criteria used in this study for NRPR included straining, incomplete evacuation, tenesmus, and the need for enemas, suppositories, or digitation. Patients who satisfied the clinical criteria were evaluated by use of anorectal physiology tests: CD, EMG, and ARM. The EMG criteria included failure to achieve a significant decrease in the electrical activity of the puborectalis (PR) during attempted evacuation. The ARM criteria included failure to achieve a significant decrease in intra-anal pressure during attempted evacuation. The CD criteria included either paradoxical contraction or failure of the PR to relax together with incomplete evacuation. Other possible etiologies for incomplete evacuation, such as rectal intussusception or rectocele, were excluded in all cases. Fifty-eight constipated patients diagnosed as having NRPR by at least one of anorectal physiolosic tests had more than one BF session. The outcomes for fifty-one patients (mean age, 44.8 years; male-to-female ratio, 22:29) were reported as either improved or unimproved at a mean follow-up of 12.7 (range, 2~30) months. The sensitivities, the specificities, and the positive and negative predictive values for the CD, EMG, and ARM diagnoses of NRPR were calculated to assess the diagnostic accuracy of each test and to identify predictors associated with the outcome of BF. RESULTS: The sensitivities of EMG, CD, and ARM were 96%, 89%, and 85%, respectively (P>0.05). The positive predictive values of the three tests were 63% for EMG, 52% for ARM, and 51% for CD (P>0.05). The negative predictive values of the three tests were 90% for EMG, 43% for ARM, and 25% for CD (P0.05). CONCLUSIONS: A combination of the CD and the EMG tests is suggested for the diagnosis of NRPR.

Outcome and Prognostic Factors Associated with Poor Outcome of Biofeedback Therapy for Constipated Patients with Non- relaxing Puborectalis Syndrome

PURPOSE: Biofeedback is a major treatment method for constipated patients with non-relaxing puborectalis syndrome. However a significant percent of patients still showed poor outcome, and little has been known about the predictors associated with outcome of biofeedback. The aim of this study was to determine the outcome and identify predictors associated with poor outcome of biofeedback therapy for constipated patients with non- relaxing puborectalis syndrome. METHODS: Fifty-two constipated patients with non-relaxing puborectalis syndrome (median age, 47 years) who had more than one biofeedback session after defecography were evaluated by standardized questionnaire, before, immediately after treatment, and at follow-up. Clinical bowel symptoms and anorectal physiological studies were analyzed. Any differences in demographics, clinical symptoms, and parameters of anorectal physiological study were evaluated between success group (patients felt improvement in symptoms at follow-up) and failure group (patients felt no improvement). RESULTS: Follow up (mean follow-up; 17 months) results were evaluated by an independent observer in 45 patients. At post-biofeedback, 42 (81 percents) patients felt improvement in symptoms, including 7 (13 percents) with complete symptom relief. At follow-up, 25 (56 percents) patients felt improvement in symptoms, including 1 (2 percents) with complete symptom relief. There was a significant reduction in difficult defecation (from 81 to 44, 53 percent, from pre-biofeedback to post-biofeedback, and at follow up respectively; P<0.005, P<0.01), sensation of incomplete defecation (from 90 to 50, 40 percent; P< 0.00001, P<0.000005), laxative use (from 25 to 10, 11 percent; P<0.05), and enema use (from 13 to 0, 2 percent; P<0.01, P<0.05). Normal spontaneous bowel movement was increased from 42 percent pre-biofeedback to 81 percent post-biofeedback (P<0.0001), 80 percent at follow up (P<0.0005). Pre-biofeedback presence of symptoms of bowel habit change predict poor outcome (15 vs. 0 percent; failure vs. success, P<0.05). High pressure zone in prebiofeedback manometry was longer in failure group than in success group (2.80 vs 2.01 cm, P<0.05). In the success group, 11 (44 percent) had a rectocele, 1 (4 percent) had a rectal intussussception, 18 (72 percent) had a descending perineal syndrome, and 3 (12 percent) had a sigmoidocele. In the failure group, 4 (20 percent) had a rectocele, and 1 (5 percent) had a rectal intussusception, 14 (70 percent) had a descending perineal syndrome, and a sigmoidocele was not accompanied (P<0.05). Accompanied rectocele, rectal intussusception, descending perineal syndrome, and sigmoidocele did not influence outcome. CONCLUSIONS: Biofeedback is an effective option and should be considered as the first line therapy. Bowel habit change and long high pressure zone in pre-biofeedback manometry were predictors associated with poor outcome of biofeedback therapy for constipated patients with non-relaxing puborectalis syndrome.

Treatment of Paradoxical Puborectalis Contraction (PPC) Using Botulinum Toxin-A

PURPOSE: Paradoxical puborectalis contraction (PPC) or Anismus is known to have a pathogenesis of abnormal contraction of puborectalis at defecation and its managements are not satisfactory. Recently, therapy of PPC and its associated symptoms using Botulinum toxin-A (BTX-A) has been introduced. we evaluate the effect of BTX-A injection to the puborectalis for the patients with PPC. METHODS: Fourteen patients were diagnosed as paradoxical puborectalis contraction on defecography and/or anorectal manometry and electromyography (EMG) during September 1998 to January 2001 in Daegu Catholic Medical Centre, Catholic University of Daegu. All patients were underwent 30 (15 15) units of BTX-A injection on each side of puborectalis guided by EMG. Among them, five patients needed further injection of 20 (10 10) units because the expected results were not satisfied. Follow-up were conducted on one month and one year after BTX-A injection and the patients were assessed for the constipation score and anorectal manometry. RESULTS: After injection of BTX-A, constipation score was significantly decreased from 15.5 +/- 3.5 (mean SD) to 5.7 +/- 4.3. Maximal resting and squeezing pressure also decreased from 48.4 +/- 22 mmHg, 96.9 +/- 39.8 to 41.2 +/- 17, 68.3 +/- 38.2, respectively. Twelve patients who were followed up more than one year after injection, the constipation score (n=12) increased up to 7.7 +/- 2.9 (mean SD). Among them, three patients have had stool softeners or laxatives to evacuate and the remained nine patients did not have any kinds of drug or food for defecation. There was no complication for the injection BTX-A. CONCLUSIONS: BTX-A injection seems to be effective for the treatment of PPC and the long term therapeutic effect can be defined through double blind placebo-controlled trials.

Psychiatric Investigation by Using the Minnesota Multiphasic Personality Inventory in Patients with Chronic Constipation

PURPOSE: Current study was designed to understand the personality and emotional composition of patients with chronic constipation. Specifically, the personality differences were evaluated in the ramified subgroups based on the physiologic characteristics. METHODS: Forty patients (31 females and 9 males) of a mean age of 48 (range, 16~86) years underwent the MMPI among 310 patients with chronic constipation. MMPI (Minnesota Multiphasic Personality Inventory) profiles were utilized for psychologic assessment for all patients prior to making diagnosis. Three validity scales of MMPI included L (Lie scale), F (Infrequency scale), K (Suppressor scale). Ten clinical scales included HS (hypochondriasis), DP (depression), HY (hysteria), PD (psychopathic deviant), MF (masculinity- feminity), PA (paranoia), PT (psychasthenia), SC (schizophrenia), MA (mania), SI (social introversion). On the basis of findings with use of anorectal physiologic studies, subgroups were categorized as patients with rectocele (A1, n=22), patient without rectocele (A2, n=18), patients with nonrelaxing puborectalis syndrome (B1, n=10), patients without nonrelaxing puborectalis syndrome (B2, n=30). The MMPI profiles were compared between subgroup patients. RESULTS: In overall patients, mean scores for scales HS, DP were elevated as compared with mean profiles (60~65 and 45~55, respectively). Male patients showed higher mean scores for scale SI than those of female patients (male vs. female; 63.5 vs. 53.9, P<0.05). A1 group showed higher mean scores for PD scale than those of A2 group (A1 vs. A2; 57.4 vs. 49.8, P=0.01). B1 group showed higher mean scores for DP scale than those of B2 group (B1 vs. B2; 67.5 vs. 59.8, P<0.05). CONCLUSIONS: Present series provided that the MMPI is a valuable tool for assessing the psychologic functioning of patients with chronic constipation. It has revealed a different personality and emotional composition in the subgroup patients based on the anorectal physiologic studies. An aspect of social introversion, psychopathic deviant and depression should be emphasized. These findings can provide the fundamental information for guideline of future diagnostic evaluation and therapy in the patients with chronic constipation.

Biofeedback Therapy in Patients with Nonrelaxing Puborectalis Syndrome: Are there differences of therapeutic effect according to methods of diagnosis?

PURPOSE: To evaluate therapeutic effect of biofeedback therapy according to methods of diagnosis in patients with norelaxing puborectalis syndrome. METHODS: From September, 1, 1998 to February, 30, 1999, the patients who were diagnosed with norelaxing puborectalis syndrome on anal electromyography (EMG) and/or cinedefecography (CD) underwent biofeedback therapy. The patients were divided into 3 groups according to the diagnostic method; CD group - only diagnosed on cinedefecography, EMG group - only diagnosed on anal electromyography, CD EMG group - diagnosed on both tests. RESULTS: Nineteen patients were diagnosed nonrelaxing puborectalis syndrome on CD and/or EMG. There were 14 females and 5 males with a mean age of 40.8+/-18.4 years. The patients were classified into CD group; five patients (26.3%); EMG group, eight patients (42.1%); CD EMG group, six patients (31.6%). The patients had 5.4 3.7 sessions of outpatient EMG-based biofeedback sessions. Subjective symptoms after biofeedback therapy improved in 4 (80.0%), 6 (75%), 5 (83%) patients in CD, EMG, CD EMG groups, respectively. There was a statistically significant increase in spontaneous bowel movements, and a reduction in assisted bowel movements after biofeedback therapy in patients in all three groups (p<0.05). However, no significant difference was found among the three groups. CONCLUSION: This study demonstrated that biofeedback therapy had a high therapeutic effect regardless to the diagnostic method. Therefore, biofeedbck therapy can be performed if one test results in the diagnosis of norelaxing puborectalis syndrome in patients with constipation.

Association between Poor Bowel Habit and Non-Relaxing Puborectalis Syndrome

PURPOSE: Constipation in children usually is due to poor bowel habit. Ignoring the urge to have a bowel movements initiates a viscious cycle of constipation. After a period of time children may stop feeling the urge, leading to fecal impaction. This leads to loss of anorectal reflex. What is the outcome of the children with long-standing poor bowel habit? METHODS: Forty-two patients with obstructed defecation (non-relaxing puborectalis syndrome) diagnosed by defecogram and anorectal manometry were investigated with rectal sensation and elasticity studies (threshold of sense: TS, defecation sensation volume: DS, maximal tolerable volume: MTV, rectal compliance: RC), and colon transit time (CTT). All detailed questionnaires on the subject were completed. Eighteen patients (11F: 7M, mean age 39 years, range 16~75) with history of poor bowel habits since childhood were compared with 24 (16F: 8M, mean age 40 years, range 16~31) with no history of poor bowel habit. RESULTS: Studies of colonic transit time demonstrated no significant difference in the right and left colon between two groups, but the rectosigmoid transit time in the poor bowel habits group was more increased than in the normal bowel habit group (P<0.05). The rectal wall compliance was increased in the poor bowel habit group as compared to the normal bowel habits group (P<0.01). Maximal tolerable volume and defecation sensation volume were greater in the poor bowel habits group than in the control group (P<0.01), but there was no significant difference in the threshold of sense between two groups. CONCLUSIONS: Prolonged poor bowel habit in childhood period leads to loss of rectal sensation, and provide an explanation for one of the pathophysiologic mechanism of non-relaxing puborectalis syndrome.