Pelvic inflammatory pseudotumor with central infectious abscess: a case report.

Inflammatory pseudotumors (IPT) are a fascinating group of lesions which involve almost all organs and tissues of the body. The clinical manifestations are diverse. Final diagnosis can only be made by meticulous microscopic examination of different areas of the tumor. A 60 year-old woman had a pelvic IPT with central infectious abscess. The lesion involved her urinary bladder, mesentery, terminal ileum, right rudimentary ovary and the abdominal wall. It mimicked malignant tumor clinically, and led to total surgical excision. Early follow-up has shown a favorable results. IPTs are extremely uncommon. The characteristic pathologic picture is a reparative fibroblastic tissue infiltrated by polymorphic inflammatory cells. Pelvic IPT, admixed with central infectious abscess, is even rarer. Prior pelvic surgery and pasteurella hemolytica infection might be causative factors in this reported case.

Patient position during cinedefecography. Influence on perineal descent and other measurements.

PURPOSE: This study was undertaken to assess the reproducibility of cinedefecography measurements and abnormal findings between the left lateral decubitus and seated positions. METHODS: Prospective patient evaluation included all patients who had lateral radiographs of the pelvis taken at rest, during squeezing, and pushing in both positions. Anorectal angle, perineal descent, and puborectalis length measurements were calculated for each set of radiographs. Pelvic floor dynamics during evacuation were measured as the changes between rest and pushing. Abnormal findings included both increased dynamic and fixed perineal descent, nonrelaxing puborectalis, and premature evacuation. RESULTS: One hundred five consecutive patients underwent cinedefecography. There were statistically significant differences between the positions with regard to anorectal angle (P < 0.0001), perineal descent (P = 0.0001), and puborectalis length (P = 0.0001). Dynamic changes of the anorectal angle, perineal descent, and puborectalis length were not significantly different (P > 0.05). However, 6 of 22 (27 percent) patients with fecal incontinence had premature evacuation severe enough to impede measurement only when seated (P = 0.05). CONCLUSION: Because of the statistically significant differences between the two positions, centers should always employ the same position for a given diagnostic group.

Anorectal manometry in the diagnosis of paradoxical puborectalis syndrome.

This prospective study was undertaken to compare the utility of anorectal manometry (ARM) with that of anal electromyography (EMG) and cinedefecography (CD) in the diagnosis of paradoxical puborectalis syndrome (PPS). One hundred sixteen consecutive patients with a history of chronic constipation were prospectively assessed. These 35 males and 81 females were of a mean age of 60 years, ranging from 18 to 84 years. The incidences of PPS were 63 percent for ARM, 38 percent for EMG, and 36 percent for CD. The correlations of PPS were suboptimal: ARM and EMG, 70 percent; and ARM and CD, 61 percent. A two-tiered system for the manometric classification of PPS was developed. First, the evacuation pressure curve pattern was classified as a normal relaxed downward (Type A; n = 43), a nonrelaxed flat or equivocal (Type B; n = 36), and a paradoxical upward (Type C; n = 37). PPS was noted with increasing incidence within curve types (21 percent in Type A, 64 percent in Type B, and 95 percent in Type C). Second, an evacuation index (EI = evacuation pressure/squeeze pressure) was defined: Group I (EI < 0; n = 43), Group II (0 < or = EI < 0.25; n = 24), Group III (0.25 < or = EI < 0.5; n = 27), and Group IV (EI > or = 0.5; n = 18). The finding of PPS also correlated with the EI group: 21 percent in Group I, 67 percent in Group II, 74 percent in Group III, and 100 percent in Group IV. This subdivision of curve types and EI groups may provide a role in the diagnosis of PPS.

Cinedefecography and electromyography in the diagnosis of nonrelaxing puborectalis syndrome.

A prospective study was undertaken to assess the correlation between electromyography (EMG) and cinedefecography (CD) for the diagnosis of nonrelaxing puborectalis syndrome (NRPR). Clinical criteria for NRPR included straining, incomplete evacuation, tenesmus, and the need for enemas, suppositories, or digitation. EMG criteria included failure to achieve a significant decrease in electrical activity of the puborectalis (PR) during attempted evacuation. CD criteria included either paradoxical contraction or failure of relaxation of the PR along with incomplete evacuation. In addition, other etiologies for incomplete evacuation, such as rectoanal intussusception or nonemptying rectocele, were excluded by proctoscopy and defecography in all cases. One hundred twelve patients with constipation, 81 females and 31 males, with a mean age of 59 (range, 12-83) years were studied by routine office evaluation, CD, and EMG. Forty-two patients (37 percent) had evidence of NRPR on CD (rectal emptying: none, 24; incomplete, 18). Twenty-eight of these patients (67 percent) also had evidence of NRPR on EMG. EMG findings of NRPR were present in 12 of 70 patients (17 percent) with normal rectal emptying. Conversely, 14 of 72 patients (19 percent) with normal PR relaxation on EMG had an NRPR pattern on CD. The sensitivity and specificity for the EMG diagnosis of NRPR were 67 percent and 83 percent, and the positive and negative predictive values were 70 percent and 80 percent, respectively. Conversely, if EMG is considered as the ideal test for the diagnosis of NRPR, CD had a sensitivity of 70 percent, a specificity of 80 percent, and positive and negative predictive values of 66 percent and 82 percent, respectively. In summary, sensitivity, specificity, and predictive values of EMG and CD are suboptimal. Therefore, a combination of these two tests is suggested for the diagnosis of NRPR.

Evaluation and treatment of chronic intractable rectal pain--a frustrating endeavor.

A study was undertaken to assess the evaluation and treatment of chronic intractable rectal pain. Sixty consecutive patients, 23 males and 37 females with a mean age of 69 (range, 29-87) years and a mean length of symptoms of 4.5 years, were evaluated by questionnaire, office examination, anal manometry, electromyography, cinedefecography, and pudendal nerve study. In all cases, organic abdominopelvic and anorectal etiologies for the pain were excluded by extensive radiologic and endoscopic evaluation. All patients had failed conservative and medical therapy. Ninety-five percent of patients had one or more associated factors: constipation or dyschezia (57 percent), prior pelvic surgery (43 percent), prior anal surgery (32 percent), prior spinal surgery (8 percent), irritable bowel syndrome (10 percent), or psychiatric disorders (depression or anxiety; 25 percent). Possible etiologies for the pain included levator spasm or anismus in 62 percent, coccygodynia in 8 percent, and pudendal neuropathy in 24 percent of patients. Therapy for pain control included electrogalvanic stimulation (EGS) in 29, biofeedback (BF) in 14, and steroid caudal block (SCB) in 11 patients. Pain control was assessed by an independent observer at a mean of 15 (range, 2-36) months after completion of therapy. Continued successful pain relief was classified by patients as good or excellent after EGS in 38 percent, after BF in 43 percent, and after SCB in 18 percent; overall success was reported by 47 percent of patients. The presence of levator spasm, coccygodynia, or pudendal neuropathy did not influence outcome. The routine use of physiologic investigation of rectal pain may not be justifiable. Moreover, more than half of the patients were refractory to all three therapeutic options used in this study.