Pelvic floor dysfunctions embrace a large series of different conditions in which functional abnormalities of the pelvic floor lead to impairment in urinary and sexual functions and in rectal voiding. A multidisciplinary approach is needed in the evaluation of these patients, as well as the adoption of imaging studies adequate to explore the complex anatomy of the region and its dynamic functionality. Available imaging studies include: endoanal and transperineal ultrasound, X-ray defecography and MR defecography. The purpose of this review article is to illustrate the technique, indications, the current role, and diagnostic value of each one of these. The recent availability of new imaging techniques and related advantages will also be discussed.

The stapled transanal rectal resection (STARR) procedure has been suggested as a simple surgical option for patients presenting with evacuatory difficulty in the clinical presence of a rectocele. Most of these patients have a multiplicity of pelvic floor pathology unaddressed by the performance of one procedure. The aim of the study was to assess an unselected group of patients referred to a tertiary coloproctological unit following performance of the STARR procedure for obstructed defecation (OD) where the procedure was complicated or had failed.Anorectal, urogynecological, and psychological examination with objective constipation/incontinence scoring, anal-vaginal-perineal ultrasound, manometry, and defecography were selectively performed utilizing the Iceberg Diagram to detect occult pelvic floor pathology.Twenty patients were referred with 13 cases (female, 10; median age, 65 years; range, 40-72) operated upon. Post-STARR surgery was performed for three complications and ten failures including recurrent OD, severe proctalgia, and fecal incontinence. Overall, 11 patients underwent biofeedback therapy and psychotherapy. Of the operated group, 11 patients had a median of four associated disorders. Seven patients had a significant psychological overlay with severe depression or anxiety and four heterogeneous anal sphincter defects. Operative procedures were tailored to the clinical findings using enterocele repair, staple removal, fistulectomy, rectosigmoid resection, and levatorplasty where appropriate. Twelve patients were evaluated after a median follow-up of 18 months. Of these, six (all with psychoneurosis) remained unchanged. Three patients with no psychological overlay were asymptomatic with a further two improved.The STARR procedure, when complicated or failed, has a poor outcome following surgical reintervention. It requires careful patient selection to determine the associated pelvic floor pathology and pre-existent psychopathology.

The pelvic floor functions as a holistic entity. The organs, bladder, bowel, smooth and striated muscles, nerves, ligaments and other connective tissues are directed cortically and reflexly from various levels of the nervous system. Such holistic integration is essential for the system's multiple functions, for example, pelvic girdle stability, continence, voiding/defecation, and sexuality. Pelvic floor dysfunction (PFD) is related to a variety of pelvic pain syndromes and organ problems of continence and evacuation. Prior to treatment, it is necessary to understand which part(s) of the system may be causing the dysfunction (s) of Chronic Pelvic Pain Syndrome (CPPS), pelvic girdle pain, sexual problems, Lower Urinary Tract Symptoms (LUTS), dysfunctional voiding, constipation, prolapse and incontinence. The interpretation of pelvic floor biomechanics is complex and involves multiple theories. Non-surgical treatment of PFD requires correct diagnosis and correctly supervised pelvic floor training. The aims of this review are to analyze pelvic function and dysfunction. Because it is a holistic and entirely anatomically based system, we have accorded significant weight to the Integral Theory's explanations of function and dysfunction.Copyright © 2021 Elsevier B.V. All rights reserved.

Anatomical damage to pelvic floor structures may cause multiple symptoms. The Integral Theory System Questionnaire (ITSQ) is a holistic questionnaire that uses symptoms to help locate damage in specific connective tissue structures as a guide to reconstructive surgery. It is based on the integral theory, which states that pelvic floor symptoms and prolapse are both caused by lax suspensory ligaments. The aim of the present study was to psychometrically validate the ITSQ.Established psychometric properties including validity, reliability, and responsiveness were considered for evaluation. Criterion validity was assessed in a cohort of 110 women with pelvic floor dysfunctions by analyzing the correlation of questionnaire responses with objective clinical data. Test-retest was performed with questionnaires from 47 patients. Cronbach's alpha and "split-half" reliability coefficients were calculated for inner consistency analysis.Psychometric properties of ITSQ were comparable to the ones of previously validated Pelvic Floor Questionnaires. Face validity and content validity were approved by an expert group of the International Collaboration of Pelvic Floor surgeons. Convergent validity assessed using Bayesian method was at least as accurate as the expert assessment of anatomical defects. Objective data measurement in patients demonstrated significant correlations with ITSQ domains fulfilling criterion validity. Internal consistency values ranked from 0.85 to 0.89 in different scenarios.The ITSQ proofed accurate and is able to serve as a holistic Pelvic Floor Questionnaire directing symptoms to site-specific pelvic floor reconstructive surgery.

Chronic anal fissure is a painful disorder caused by linear ulcers in the distal anal mucosa. Even though it counts as one of the most common benign anorectal disorders, its precise etiology and pathophysiology remains unclear. Current thinking is that anal fissures are caused by anal trauma and pain, which leads to internal anal sphincter hypertonia. Increased anal basal pressure leads to diminished anodermal blood flow and local ischemia, which delays healing and leads to chronic anal fissure. The current treatment of choice for chronic anal fissure is either lateral internal sphincterotomy or botulinum toxin injections. In contrast to current thinking, we hypothesize that the external, rather than the internal, anal sphincter is responsible for increased anal basal pressure in patients suffering from chronic anal fissure. We think that damage to the anal mucosa leads to hypersensitivity of the contact receptors of the anal-external sphincter continence reflex, resulting in overreaction of the reflex. Overreaction causes spasm of the external anal sphincter. This in turn leads to increased anal basal pressure, diminished anodermal blood flow, and ischemia. Ischemia, finally, prevents the anal fissure from healing. Our hypothesis is supported by two findings. The first concerned a chronic anal fissure patient with increased anal basal pressure (170mmHg) who had undergone lateral sphincterotomy. Directly after the operation, while the submucosal anesthetic was still active, basal anal pressure decreased to 80mmHg. Seven hours after the operation, when the anesthetic had completely worn off, basal anal pressure increased again to 125mmHg, even though the internal anal sphincter could no longer be responsible for the increase. Second, in contrast to previous studies, recent studies demonstrated that botulinum toxin influences external anal sphincter activity and, because it is a striated muscle relaxant, it seems reasonable to presume that it affects the striated external anal sphincter, rather than the smooth internal anal sphincter. If our hypothesis is proved correct, the treatment option of lateral internal sphincterotomy should be abandoned in patients suffering from chronic anal fissures, since it fails to eliminate the cause of high anal basal pressure. Additionally, lateral internal sphincterotomy may cause damage to the anal-external sphincter continence reflex, resulting in fecal incontinence. Instead, higher doses of botulinum toxin should be administered to those patients suffering from chronic anal fissure who appeared unresponsive to lower doses. Copyright © 2016 Elsevier Ltd. All rights reserved.

Obstructed defecation symptoms (ODS) are common in women; however, the key underlying anatomic factors remain poorly understood. We investigated rectal mobility and support defects in women with and without ODS using pelvic floor ultrasound and MR defecography.This prospective case-control study categorized subjects based on questions 7, 8 and 14 on the PFDI-20, which asks about obstructed defecation symptoms. All subjects underwent an interview, examination and pelvic floor ultrasound, and a subset of 16 subjects underwent MR defecography. The cul de sac-to-anorectal junction distance at rest and during maximum strain was measured on ultrasound and MRI images. The 'compression ratio' was calculated by dividing the change in rectovaginal septum length by its rest length to quantify rectal folding and hypermobility during dynamic imaging and to correlate with ODS.Sixty-two women were recruited, 32 cases and 30 controls. There were no statistically significant differences in age, parity, BMI or stage of rectocele between groups. A threshold analysis indicated the risk of ODS was 32 times greater (OR 32.5, 95% CI 4.8-217.1, p = 0.0003) among women with a high compression ratio (≥ 14) compared with those with a low compression ratio (< 14) after controlling for age, BMI, parity, stool type and BM frequency.Female ODS are associated with distinct alterations in rectal mobility and support that can be clearly observed on dynamic ultrasound. The defects in rectal support were quantifiable using a compression ratio metric, and these defects strongly predicted the likelihood of symptoms; interestingly, the presence or degree of rectocele defects played no role. These findings may provide new insight into the anatomic factors underlying female ODS.

Zusammenfassung. Die MRI-Bildgebung eignet sich ausgezeichnet 1) zum Staging des Rektumkarzinoms, 2) zur Abklärung von chronisch-entzündlichen Darmkrankheiten und 3) zur Defäkographie. 1) Die MRI-Accuracy bezüglich richtigem T-Stadium beziehungsweise N-Stadium liegt bei 75 – 95 % und 71 – 85 %, insbesondere die Tumorinfiltration ins mesorektale Fettgewebe ist im MRI sehr gut beurteilbar. 2) Durch den hohen Weichteilkontrast des MRIs können perirektale und perianale Abszesse, Fisteln und deren Bezug zu den Analsphinkteren und dem M. levator ani, sowie der Therapieerfolg einfach eingesehen werden. Zudem lässt sich auch die Aktivität der Grundkrankheit im Rektum einfach bestimmen. 3) MRI-Movie-Sequenzen erlauben die Beurteilung der Dynamik in der Defäkographie. Damit lässt sich die paradoxe Kontraktion der puborektalen Schlinge beim Anismus (Dyskinesie) darstellen. Auch ein Beckenbodendeszensus, eine Inkontinenz, eine Rektozele oder Enterozele kann mit den Movie-Sequenzen detektiert werden.

Our primary objective was to determine the association between rectocele size on defecography and physical examination in symptomatic patients. Our secondary objective was to describe the associations between both defecography and physical examination findings with defecatory symptoms and progression to surgical repair of rectocele.

More common in older women than younger women, rectoceles may be secondary to pelvic floor weakness and/or pelvic floor dysfunction with impaired rectal evacuation. Rectoceles may be small (&lt;2 cm), medium (2–4 cm), or large (&gt;4 cm). Arguably, large rectoceles are more likely to be associated with symptoms (e.g., difficult defecation). It can be challenging to ascertain the extent to which a rectocele is secondary to pelvic floor dysfunction and/or whether a rectocele, rather than associated pelvic floor dysfunction, is responsible for symptoms. Surgical repair should be considered when initial treatment measures (e.g., bowel modifying agents and pelvic floor biofeedback therapy) are unsuccessful.

Surgical treatment of rectocele represents a controversial issue on the boundary between medical specialisations with many different corrective surgical techniques. Is it possible, based on the available knowledge, to determine an optimal operative technique for rectocele repair?Complex literature search focusing on the identification of rectocele surgical repair studies in the MEDLINE, PubMed and Google Scholar databases. The aim of this paper is to offer a comprehensive review of the contemporary situation as regards rectocele surgical repair.There are four main possible approaches for rectocele repair - transvaginal, transanal, transperineal and transabdominal. Posterior colporrhaphy with levatoroplasty is the traditional transvaginal technique, performed at most gynaecological departments in various modifications. Defect-specific rectocele repair and mesh repair represent newer transvaginal techniques which offer better postoperative functional results, although with the risk of possible serious complications. Traditional transanal rectocele repair (vertical and horizontal plication of the rectovaginal septum) is currently performed only rarely due to its worse results in comparison with the transvaginal approach. Rectal resection using endostaplers (STARR and TRANSTAR techniques) is a modern transanal technique. Stapled rectocele repair leads to the correction of anorectal anatomical conditions and to the improvement of obstructive defecation symptoms with acceptable morbidity. Transperineal approach is usually used in patients with rectocele and anal incontinence due to a proven sphincter defect. Transabdominal laparoscopic approach is based on vaginorectopexy by means of mesh implantation, and it is indicated especially in patients with rectocele and enterocele.Based on the results of published studies, it is not possible to determine clear guidelines for rectocele surgical repair. Posterior colporrhaphy and stapled transanal repair are the most common techniques in practice. Prospective randomized studies focusing on the comparison between transvaginal and stapled transanal approach for rectocele repair are needed.

Obstructed defecation syndrome represents 50–60% of patients with symptoms of constipation. We aimed to compare the two frequently performed surgical methods, laparoscopic ventral mesh rectopexy and transperineal mesh repair, for this condition in terms of functional and surgical outcomes.

Background: Rectocele is defined as a defect in the rectovaginal septum, causing symptoms like obstructed defecation syndrome (ODS), vaginal bulging, etc. Once the rectocele is larger than 3 cm and/or symptomatic, surgery should be considered. The surgical approach can be either transvaginal, transanal or transperineal. Two of the most common procedures in treating rectocele are posterior colporrhaphy (PC) and stapled trans anal rectal resection (STARR). The purpose of this study was to compare surgical outcomes of both procedures. Methods: This is a retrospective cohort study. Included were patients of the age of 18–85 years that underwent either STARR (n = 49 patients) or PC (n = 24 patients) procedures after a full clinical (defecography and physical exam before and after the surgery) and physiologic (a detailed questionnaire before and after the surgery) surveys. Symptoms of ODS before and after surgery were evaluated by questioners. Results: Preoperatively, the patients in the STARR group had significantly higher rates of ODS: straining (90.9% vs. 65.2%), incomplete evacuation (100% vs. 69.6%), hard stool (57.8% vs. 43.5%), sense of obstruction (76.1% vs. 56.5%), and use of digitation (64.4% vs. 47.8%), or laxatives (70% vs. 47.8%), p &lt; 0.001. Anatomically, the mean rectocele size was smaller for the STARR group, compared to the PC group (3.8 ± 1.4 vs. 5.3 ± 2.2 cm, respectively, p &lt; 0.001). Postoperatively, in the STARR group, higher rates of patients complained about straining (36.4% vs. 21.7%, p &lt; 0.001) and use of digitation (64.4% vs. 26.1%, p &lt; 0.001), whereas lower rates of patients complained about incomplete evacuation (41.2% vs. 56.5%, p = 0.05) and sense of obstruction (17.6%, vs. 34.8%, p = 0.03), compared to the PC group. Among patients who underwent the STARR procedure, a decrease in rates of all symptoms was noted (straining 54.5%, incomplete evacuation 58.8%, hard stool 29.2%, sense of obstruction 58.5%, use of digitation 0.1%, and use of laxatives 31.5%). Both procedures are effective in reducing rectocele size (STARR- 1.9 ± 1 cm, PC- 3.1 ± 1). Conclusions: Both STARR and PC are effective in treating rectocele. It seems that the STARR procedure is superior to the PC procedure in treating symptoms of ODS.

Rectocele is commonly seen in parous women and sometimes associated with symptoms of obstructed defecation syndrome (ODS).To assess the current literature in regard to the outcome of the classical transperineal repair (TPR) of rectocele and its technical modifications.An organized literature search for studies that assessed the outcome of TPR of rectocele was performed. PubMed/Medline and Google Scholar were queried in the period of January 1991 through December 2020. The main outcome measures were improvement in ODS symptoms, improvement in sexual functions and continence, changes in manometric parameters, and quality of life.After screening of 306 studies, 24 articles were found eligible for inclusion to the review. Nine studies (301 patients) assessed the classical TPR of rectocele. The median rate of postoperative improvement in ODS symptoms was 72.7% (range, 45.8%-83.3%) and reduction in rectocele size ranged from 41.4%-95.0%. Modifications of the classical repair entailed omission of levatorplasty, addition of implant, concomitant lateral internal sphincterotomy, changing the direction of plication of rectovaginal septum, and site-specific repair.The transperineal repair of rectocele is associated with satisfactory, yet variable, improvement in ODS symptoms with parallel increase in quality-of-life score. Several modifications of the classical TPR were described. These modifications include omission of levatorplasty, insertion of implants, performing lateral sphincterotomy, changing the direction of classical plication, and site-specific repair. The indications for these modifications are not yet fully clear and need further prospective studies to help tailor the technique to rectocele patients.©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.

   Aim: to assess of late results of original method of rectocele repair with non-absorbable polypropylene W-form mesh.   Patients and methods: the pilot study included 37 patients which underwent surgery for rectocele repair using original technique of W-mesh. The late results were assessed in 21 (56.6 %) of them ≥ 6 month after surgery. Before the surgery and 6 months after, patients underwent a clinical assessment of symptoms. Specialized questionnaires for assessment of constipation (Colonic evacuation disorder scale, PFDI-20, Cleveland Clinic Constipation Score) were used. Defecography and anorectal manometry were performed before and in 6-months after surgery for evaluation of pelvic floor disorders.   Results: no obstructive defecation symptoms were revealed in 85.7% of patients 6 month after surgery.In ≥ 6 months after surgery all questionnaires showed decrease in scores by more than 2 times. Comparison of the results before and 6 months after the surgery showed significant differences for all questionnaires (p &lt; 0.0001). According to defecography performed before and after the surgery a significant reduction (p &lt; 0.05) of rectocele depth, time of rectal voiding (decreased by 1.5 times) and residual volume of contrast agent (decreased by 2.5 times) were revealed. There are no severe complications requiring re-operation were observed.   Conclusion: transvaginal mesh repair of symptomatic rectocele demonstrated good clinical results 6 months after surgery. Good results were revealed in 85,7 % of patients confirmed by specialized questionnaires and defecography.

In 45 years, the definitions and practice of the urodynamically based overactive bladder (OAB)/detrusor overactivity (DO) system have failed to adequately address pathogenesis and cure of urinary urge incontinence, frequency and nocturia.We analysed the OAB syndrome with reference to the Integral Theory paradigm's (ITS) binary feedback system, where OAB in the female is viewed as a prematurely activated, but otherwise normal micturition caused mainly, but not entirely, by ligament damage/laxity. The ITS Clinical Assessment Pathway which details the relationships between structural damage (prolapse), ligaments and dysfunction (symptoms) is introduced.The ITS was able to "better explain" OAB pathophysiology in anatomical terms with reference to the binary model. The phasic patterns diagnostic of "detrusor overactivity" are explained as a struggle for control by the closure and micturition reflexes. The exponentially determined relationship between urethral diameter and flow explains why obstructive patterns occur, why they do not and why urine may leak with no recorded pressure. Mechanically supporting ligaments ("simulated operations") during urodynamic testing can improve low urethral pressure, negative pressure during coughing with SUI and diminish urge sensation or even DO patterns, transforming urodynamics from non-predictive test to accurate predictor of continence surgery results. High cure rates for OAB by daycare repair of damaged ligaments is a definitive test of the binary system's validity.Conceptual progression of OAB to the Integral Theory paradigms's prematurely activated micturition validates OAB component symptoms as a syndrome, explains pathogenesis, and unlocks a new way of understanding, diagnosing, treating and researching OAB.© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.