Defecography: does parity play a role in the development of rectal prolapse?

Few studies related to parity address the changes in anorectal function in women. Since the majority of patients with rectal prolapse are women, we undertook this study to assess the role of parity in the development of rectal prolapse. We retrospectively reviewed defecography studies performed on 354 female patients over a 10-year period. Studies noting the presence of intra-anal and external rectal prolapse (full thickness protrusion of the rectum into and through the anal sphincter) were reviewed. Cases with intrarectal or hidden rectal prolapse, a condition of lesser clinical importance, were excluded. The obstetric histories of the patients with rectal prolapse (n = 27) were compared to those of patients without rectal prolapse (n = 88). There was a larger proportion of nulliparous women in the rectal prolapse group than in the group without rectal prolapse, suggesting that factors in addition to parity play a role in the development of rectal prolapse. However, parous women with rectal prolapse had delivered significantly more children (3.3) than parous women without prolapse (2.5) (P = 0.03). The exact cause of rectal prolapse remains unclear. Childbearing appears to play a limited role in its pathogenesis since nulliparous women are also at risk of developing rectal prolapse.

The role of parity and hysterectomy on the development of pelvic floor abnormalities revealed by defecography.

OBJECTIVE: The purpose of our study was to assess the role of multiparity and pelvic surgery, especially hysterectomy, on pelvic floor dysfunction as diagnosed on defecography. MATERIALS AND METHODS: Three hundred fifty-four women who underwent defecography between 1986 and 1996 were asked to provide information regarding obstetric history and pelvic surgery. Responses were obtained from 272 women (response rate, 77%). Their presenting symptoms ranged from incontinence to constipation and obstructed defecation. Historical data were correlated with incidence of defecographic abnormalities that included rectocele, enterocele, rectal prolapse, incontinence, excessive pelvic floor descent, and dyskinetic puborectal muscle. RESULTS: Women with three or more birth deliveries were more likely to have incontinence (48% versus 36%, p = .05) and excessive pelvic floor descent (26% versus 17%, p = .07) than women who had delivered fewer children. Women undergoing hysterectomy before defecography were more likely to have enterocele (40% versus 25%, p = .009) and excessive pelvic floor descent (25% versus 15%, p = .04) than women who had never undergone hysterectomy. CONCLUSION: Our findings confirm the common belief that trauma from childbirth or hysterectomy contributes to the development of defecation disorders.

Is constipation a disorder of defecation or impaired motility?: distinction based on defecography and colonic transit studies.

OBJECTIVE: The purpose of this study was to determine whether constipation is a disorder of defecation or of impaired motility by using defecography and transit studies. MATERIALS AND METHODS: Thirty-five patients (34 women, one man) with severe constipation underwent defecography and colonic transit studies in a 2-month period. Transit studies included the use of orally administered radiopaque markers and plain abdominal radiographs obtained up to 4 days later. Fluoroscopically guided defecography was performed with barium paste introduced into the rectum. RESULTS: Normal colonic transit time was observed in seven (20%) of the 35 patients. Abnormal findings included colonic inertia in six (17%) patients, hindgut dysfunction in 10 (29%) patients, and outlet obstruction in 12 (34%) patients. Rectocele, enterocele, descending perineum syndrome, and dyskinetic puborectalis were found equally in both groups of patients. Rectal prolapse was more commonly found in patients with hindgut dysfunction and outlet obstruction (p < .05). CONCLUSION: Surgical or medical management of severely constipated patients relies on objectively identifying the underlying pathophysiology. Our findings suggest that constipation is often a disorder of defecation rather than an impairment of colonic motility.

Cutaneous ileocystostomy (a bladder chimney) for the treatment of severe neurogenic vesical dysfunction.

The aim of this study was to investigate the efficacy and morbidity of cutaneous ileocystostomy, as an alternative to cystectomy and ileal conduit urinary diversion, for patients with end-stage neurogenic vesical dysfunction. Three male and eight female patients, mean age 41 years (range 28-59), with a mean duration of a neuropathic bladder of 8 years (range 4-17 years) underwent evaluation for ileocystostomy urinary diversion. Indications for the procedure included a bladder capacity < or = 200 ml (10 patients), recurrent febrile urinary tract infection (nine patients), and urinary incontinence despite an indwelling urethral catheter (all eight women). Each was felt to be a poor candidate for, or refused, continent urinary diversion or bladder augmentation cystoplasty. All eight females required concomitant pubovaginal sling urethral compression to eliminate urinary leakage from a patulous, non-functional urethra. Two patients required bilateral ureteral reimplantation for grade III-IV/V reflux. Effective low-pressure urinary stomal drainage was achieved without the need for chronic catheterization in all of the patients with a mean duration of follow-up of 24 months (range 6-60 months). No patient has developed pyelonephritis since the procedure. Urethral urinary leakage was eliminated in all of the female patients, whilst vesicoureteral reflux resolved in those with reflux preoperatively.

Esophageal strictures: findings on barium radiographs.

An esophageal stricture is a narrowing of the lumen due to inflammation or tumor. Lack of distensibility is characteristic of stricture, which may be diffuse or localized and which may have abrupt or tapered margins. The purpose of this essay is to illustrate the imaging features of various types of strictures, focusing on their value in differential diagnosis.

Improved quality of life and sexuality with continent urinary diversion in quadriplegic women with umbilical stoma.

Quality of life issues prompted us to offer continent urinary diversion to quadriplegic women who required cystectomy for end-stage neurogenic vesical dysfunction complicated by urethral destruction as a result of chronic indwelling catheterization. Three women with spinal cord injury (SCI) and resultant quadriplegia of 5 to 15 years duration underwent continent urinary diversion. Preoperative evaluation and urodynamic studies in each showed a bladder capacity of less than 150mL, bilateral vesicoureteral reflux, recurrent febrile urinary tract infections, an incompetent urethral sphincter, and incontinence around an indwelling catheter in all three patients. Although highly motivated, these women showed minimal dexterity and were unable to perform urethral self-catheterization. Each was opposed to having an incontinent abdominal urinary stoma. The urinary reservoir was created from 30cm of detubularized right colon. The continence mechanism used an intussuscepted and imbricated ileocecal valve. The umbilicus was chosen as the urostomy site because of cosmetic appearance and ease of catheterization for a patient with minimal dexterity. Follow-up ranged from 18 to 30 months. Reservoir capacity ranged from 550 to 800mL without evidence of reflux or stomal leakage. The incidence of symptomatic autonomic dysreflexia and urinary tract infection decreased postoperatively in all patients. Of the two women who were sexually active, the frequency of activity increased from 8 to 15 episodes per month in one and 3 to 4 episodes per month in the other. Both reported improved sexual enjoyment. Body image and satisfaction with urologic management increased in all three patients. In conclusion, continent urinary diversion in selected quadriplegic patients is a reasonable alterative to incontinent intestinal urinary diversion. The umbilical stoma provides an excellent cosmetic result which patients with minimal dexterity are able to catheterize easily. Continent urinary diversion in women results in improved self-image, quality of life, and enables greater sexual satisfaction.

Trends in use of barium enema examination, colonoscopy, and sigmoidoscopy: is use commensurate with risk of disease?

PURPOSE: To assess replacement of barium enema examination with colonoscopy in relation to age- and sex-related risk factors, place of service, physician specialty, and cost. MATERIALS AND METHODS: Between 1985 and 1992, 894,777 insurance claims for barium enema examination and lower gastrointestinal endoscopy were retrospectively examined. Changes in use were investigated. Use of proctosigmoidoscopy and flexible sigmoidoscopy, two office-based endoscopic procedures, was also examined. RESULTS: Use of diagnostic colonoscopy increased from 191 to 406 services per 100,000 persons; colonoscopy with biopsy, from 77 to 183 services; and colonoscopy with lesion removal, from 77 to 202 services. Barium enema examination use declined from 929 to 511 services per 100,000 persons; diagnostic proctosigmoidoscopy, from 854 to 193 services; and diagnostic flexible sigmoidoscopy, from 656 to 620 services. Increases in use of colonoscopy in patients aged younger than 40 years were greater than overall increases. CONCLUSION: Colonoscopy has been replacing barium enema examination as the initial colorectal examination since 1985. Increased use of colonoscopy in patients with lower risk of neoplasia suggests that indications have become overly broad.

Intraoperative endo-luminal ultrasound evaluation of urethral diverticula.

The imaging accuracy of a catheter-based endo-luminal ultrasound system was compared to traditional imaging techniques for surgical treatment of urethral diverticula in 7 women and 1 man. At surgical repair the urethra was catheterized directly with a 6.2F or 9F (12.5 or 20 MHz.) catheter-based ultrasound transducer, generating a 360-degree transaxial real-time image. The endo-luminal ultrasound images were compared with preoperative voiding cystourethrography (7 patients), transvaginal ultrasound examinations (3) and double balloon urethrograms (2). Surgical diverticulectomy was then done with endo-luminal ultrasound monitoring. Intraoperatively, all diverticula were well visualized by endo-luminal ultrasound, which demonstrated improved identification of the size and orientation of urethral diverticula, sludge within the diverticula, the extent of periurethral inflammation, diverticular wall thickness, and the distance between the diverticular wall and urethral lumen. In 3 patients the urethral connections of the diverticula were exceptionally well visualized. Comparison with traditional imaging revealed 2 false-negative and 1 false-positive voiding cystourethrograms, 1 false-negative transvaginal ultrasound study and 1 false-negative double balloon urethrogram. Intraoperative monitoring of the urethra enabled precise anatomical dissection, eliminated all diverticular components, and prevented inadvertent urethral and bladder neck injury. Urethral endo-luminal ultrasound is a valuable new adjunct in the evaluation of a variety of urethral abnormalities. This new ultrasound application permits visualization of the precise size, location, orientation and characteristics of urethral diverticula and surrounding tissues. Through enhanced imaging, surgical repair is facilitated. Further application of this technique should increase the diagnostic accuracy of urethral imaging beyond radiographic techniques currently available.

Functional urethral closure with pubovaginal sling for destroyed female urethra after long-term urethral catheterization.

OBJECTIVE: To assess the pubovaginal sling as therapy for correction of the destroyed female urethra secondary to long-term indwelling Foley catheter management of neurogenic vesical dysfunction. METHODS: Fourteen women with neurologic disease and a patulous and nonfunctioning urethra underwent pubovaginal sling functional urethral closure. The purpose of the procedure is to achieve a dry perineum. Greater tension is applied to the sling suspension for urethral closure than is normally used to ensure continence for patients exhibiting intrinsic sphincter dysfunction without neurogenic vesical dysfunction. RESULTS: Two patients with adequate bladder capacity and compliance underwent only a pubovaginal sling suspension. They were subsequently managed with intermittent catheterization. In 5 patients, a sling operation in conjunction with enterocystoplasty was accomplished. In 5 patients, a sling procedure with an ileocystostomy and a cutaneous urostomy (bladder chimney) was utilized. In 2 patients, suprapubic tube drainage was established at the time of pubovaginal sling placement. All patients have achieved continence, without the need for absorbent pads, with follow-up time of six to sixty months (mean, 24 months). Abdominal wall herniation has not developed in any patient. CONCLUSIONS: The pubovaginal sling cured incontinence and has resulted in a dry perineum with few problems. The sling procedure may be superior to transabdominal or transvaginal bladder neck closure without the risk of fistula formation.

Prospective comparison of external sphincter balloon dilatation and prosthesis placement with external sphincterotomy in spinal cord injured men.

The purpose of our investigation was to compare external sphincterotomy, the traditional method of treatment of detrusor-external sphincter dyssynergia (DESD), with two newer methods, balloon dilatation or internal stenting of the external sphincter. Sixty-one spinal cord injured (SCI) men were prospectively evaluated. The indications for treatment were DESD and voiding pressure greater than 60 cmH2O demonstrated during video-urodynamic study. Twenty patients were treated with balloon dilatation of the external sphincter, 26 with an internal stent prosthesis, and 15 with traditional external sphincterotomy. Age and duration of SCI were similar among the three treatment groups. A significant decrease in both voiding pressure and residual urine from presurgery levels persisted during the follow-up period of 3 to 26 months (mean, 15 months) in all three groups. Bladder capacity remained constant, renal function improved or stabilized, and autonomic dysreflexia (AD) improved in all three groups. Balloon dilatation and prosthesis placement are associated with a significantly shorter length of surgery (p = 0.045), length of hospitalization (p = 0.005), decrease in hospitalization cost (p = 0.01), and decrease in hemoglobin postoperatively (p = 0.046) when compared to external sphincterotomy. Complications of stent insertion included device migration (three patients) and secondary bladder neck obstruction (two patients). In the balloon dilatation group, three recurrent sphincter obstructions, one case of bleeding requiring transfusion, and one case of bulbous urethral stricture occurred. After external sphincterotomy, two patients developed recurrent obstruction, two required blood transfusion, and 1 patient noted erectile dysfunction. Balloon dilatation and prosthesis placement both proved to be as effective as external sphincterotomy in the treatment of DESD.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost containment in the use of low-osmolar contrast agents: effect of guidelines, monitoring, and feedback mechanisms.

PURPOSE: To describe a program for controlling intravenous use of low-osmolar contrast agents (LOCAs). MATERIALS AND METHODS: The department of radiology at the authors' institution adopted a policy of selective use of intravenously administered LOCAs. Clinical indications for LOCA use were specified after consultation with the administration, risk managers, legal department, and ethics committee of the hospital. The guidelines were then publicized throughout the department and hospital, and a contrast agent data form was developed to collect data on all cases. Monitoring mechanisms were instituted. RESULTS: Over the next 23 months, 11,373 patients received intravenous iodinated contrast agents, of whom 28.1% were deemed to be at high risk and were given LOCAs. Monthly tracking showed no evidence of a trend toward increasing use of LOCAs. CONCLUSION: Clear definition of use guidelines, close monitoring, and feedback can stabilize LOCA use at acceptably low levels.

Transurethral balloon dilation of the external urinary sphincter: effectiveness in spinal cord-injured men with detrusor-external urethral sphincter dyssynergia.

The authors investigated balloon dilation as a minimally invasive alternative to transurethral external sphincterotomy for the treatment of detrusor-external urethral sphincter dyssynergia (DESD). Seventeen spinal cord-injured men with voiding pressures greater than 60 cm H2O underwent balloon dilation of the external sphincter to 90 F at 4 atm of pressure for 10 minutes. The mean voiding pressures before and 12 months after dilation were 83 cm H2O +/- 35 and 37 cm H2O +/- 15, respectively (P = .008). There was a significant decrease in residual urine volume, from 163 mL +/- 162 to 68 mL +/- 59 (P = .05), whereas bladder capacity remained relatively unchanged at 253 mL +/- 181 and 230 mL +/- 97 (P = .30). Complications included one case of postoperative bleeding necessitating transfusion, two treatment failures, and one bulbous urethral stricture. Fourteen of the 17 patients (82%) now void without the aid of an indwelling catheter or alternative therapy. Balloon dilation has no detrimental effect on erectile function and may improve fertility.

Functional disorders of the anus and rectum: findings on defecography.

In the past decade, interest in the anorectal region and the mechanism of continence and defecation has been increasing. Subsequently, techniques to visualize the anorectum have been introduced; evacuation proctography and defecography have been used to describe the dynamic radiologic evaluation of this area. Also, developments in anorectal manometry, electromyography, and transrectal sonography have renewed interest in defecography, particularly in categorizing the functional disorders including rectocele, intussusception and prolapse, enterocele, descending perineum syndrome, dyskinetic puborectalis muscle, solitary rectal ulcer syndrome, and incontinence.

Hysterosalpingography before and after myomectomy: clinical value and imaging findings.

OBJECTIVE: Myomectomy is being performed increasingly for the treatment of menorrhagia and infertility. The purpose of this study was to describe the findings at hysterosalpingography before and after myomectomy and to correlate the findings with the operative technique and observations at surgery. This study also examined the value of hysterosalpingography in planning surgery, as well as in detecting postoperative complications and residual fibroids. MATERIALS AND METHODS: The study group comprised 32 patients who were consecutively referred for hysterosalpingography after myomectomy. The indications for myomectomy were infertility in all cases, associated with menorrhagia in 20, pelvic pain in 15, and urinary frequency in eight. Eighteen of the 32 patients also had hysterosalpingography before surgery. The hysterosalpingographic findings were reviewed without knowledge of the clinical findings and then correlated with surgical and pathologic findings. RESULTS: Preoperative hysterosalpingograms showed enlargement and/or distortion of the uterine cavity in 13 of 14 patients who had submucous fibroids or mural fibroids with a submucous component (mural/submucous fibroid). Cornual asymmetry was seen in seven of 18 patients, the result of an adjacent fibroid deforming one bilaterally in another two. In all four patients, tubal patency was shown after myomectomy. Intracavitary filling defects consistent with submucous or mural/submucous fibroids were found in 12 of 18 patients. After myomectomy, these defects resolved in eight cases; in the remaining four, persistent filling defects suggested residual submucous enlargement of the uterine cavity in only two of 32 patients; in both, residual mural and/or submucous fibroids were shown on sonography after surgery. Major distortion of the cavity after surgery was found in four patients; it was caused by filling defects consistent with residual submucous fibroids in two and by major synechiae in two. Diverticula at the site of resection of submucous fibroids were found in six patients. Major synechiae were found in two patients, resulting in unilateral or bilateral tubal occlusion. CONCLUSION: Hysterosalpingography before myomectomy can assist the surgeon in planning the surgical approach by showing the presence, size, and location of submucous fibroids and concomitant tubal disease. Hysterosalpingography after myomectomy shows residual fibroids and complications of surgery, such as synechiae and diverticula, that may affect further treatment.

Imaging of uterine leiomyomas.

Advances in the medical and surgical treatment of uterine leiomyomas have stimulated interest in the imaging of these common tumors. The purpose of this essay is to illustrate the appearance of leiomyomas on images obtained with various techniques. The advantages of each technique in particular clinical circumstances are discussed.

Giant cell tumor of tendon sheath: spectrum of radiologic findings.

Giant cell tumor of tendon sheath is the second most common tumor of the hand. It can also occur in larger joints. Radiologic features include a soft-tissue mass with or without osseous erosion. Less commonly, it can cause periostitis or permeative osseous invasion; it may rarely calcify. The entire imaging spectrum of this lesion is presented, with emphasis on atypical appearances which can mimic other lesions.

Hysterosalpingography.

During the past decade, there has been a dramatic increase in the number of women seeking infertility evaluation. Hysterosalpingography (HSG) is an invaluable procedure for evaluating internal architecture of the female reproductive tract. Utilizing HSG, it may be possible to minimize the use of invasive procedures, such as hysteroscopy and laparoscopy, in defining such problems as peritubal adhesions, leiomyomas, and congenital anomalies. This review re-emphasizes the wide range of available information and advantages of HSG which can be extremely useful in the diagnosis and management of infertile patients.