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Persistent levator co-activation is not associated with symptoms or bother of obstructed defecation

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Abstract

Introduction and hypothesis

The objective was to determine whether levator contraction during Valsalva (i.e. levator co-activation), as visualised on four-dimensional translabial ultrasound (4D-TLUS), is associated with obstructed defecation (OD).

Methods

This was a retrospective study including patients attending a tertiary urogynecological unit. All underwent an interview, clinical examination and 4D-TLUS. Frequent straining at stool, digitation or sensation of incomplete emptying during defecation were considered symptoms of OD. Archived 4D-TLUS volumes were evaluated, blinded to all other data. Hiatal anteroposterior (AP) diameter (cm) and hiatal area (cm2) were measured at rest and on maximal Valsalva. Patients with anatomical explanations for OD (rectocele, enterocele and/or rectal intussusception) were excluded. Reduction of hiatal AP diameter and hiatal area on Valsalva were tested for association with symptoms of OD.

Results

Overall, 1,383 women attended the unit from May 2013 to July 2016. Seven hundred and eight were excluded because of rectocele (n = 645), enterocele (n = 116) or rectal intussusception (n = 41) and 10 owing to missing data, leaving 665. Mean age was 53 years (16–89), mean body mass index (BMI) 27.3 kg/m2 (15.7–64.4). OD symptoms were reported by 368 (55.3%) patients. On imaging, a reduction in hiatal AP diameter on Valsalva was seen in 11.7% cases (78 out of 665) with a mean reduction of 3.5 mm (0.2–17). A mean reduction in hiatal area of 1.9cm2 (0.03–14.8) on Valsalva was seen in 9.8% cases (65 out of 665). These sonographic measures of levator co-activation were not associated with OD symptoms or bother caused by them (p > 0.05).

Conclusions

Levator co-activation seen on TLUS is not associated with obstructed defecation.

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References

  1. Sultan AH, Monga A, Lee J, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female anorectal dysfunction. Neurourol Urodyn. 2017;36(1):10–34.

    Article  Google Scholar 

  2. Andromanakos N, Skandalakis P, Troupis T, et al. Constipation of anorectal outlet obstruction: pathophysiology, evaluation and management. J Gastroenterol Hepatol. 2006;21(4):638–46.

    Article  Google Scholar 

  3. Rao SSC, Patcharatrakul T. Diagnosis and treatment of dyssynergic defecation. J Neurogastroenterol Motil. 2016;22(3):423–35.

    Article  Google Scholar 

  4. Carter D, Bardan E, Maradey-Romero C. Clinical and physiological risk factors for fecal incontinence in chronically constipated women. Techniques in Coloproctology. 2019;23:429–34.

    Article  CAS  Google Scholar 

  5. Murad-Regadas SM, Rodrigues LV, Furtado DC, et al. The influence of age on posterior pelvic floor dysfunction in women with obstructed defecation syndrome. Tech Coloproctol. 2012;16(3):227–32.

    Article  CAS  Google Scholar 

  6. Van Gruting IMA, Stankiewicz A, Kluivers K, et al. Accuracy of four imaging techniques for diagnosis of posterior pelvic floor disorders. Obstet Gynecol. 2017;130(5):1017–24.

    Article  Google Scholar 

  7. Perniola G, Shek C, Chong CC, et al. Defecation proctography and translabial ultrasound in the investigation of defecatory disorders. Ultrasound Obstet Gynecol. 2008;31(5):567–71.

    Article  CAS  Google Scholar 

  8. Martellucci J, Naldini G. Clinical relevance of transperineal ultrasound compared with evacuation proctography for the evaluation of patients with obstructed defaecation. Colorectal Dis. 2011;13(10):1167–72.

    Article  CAS  Google Scholar 

  9. Orno AK, Dietz HP. Levator co-activation is a significant confounder of pelvic organ descent on Valsalva maneuver. Ultrasound Obstet Gynecol. 2007;30(3):346–50.

    Article  CAS  Google Scholar 

  10. Grossi U, Carrington EV, Bharucha AE, et al. Diagnostic accuracy study of anorectal manometry for diagnosis of dyssynergic defecation. Gut. 2016;65(3):447–55.

    Article  Google Scholar 

  11. Noelting J, Ratuapli SK, Bharucha AE, et al. Normal values for high-resolution anorectal manometry in healthy women: effects of age and significance of rectoanal gradient. Am J Gastroenterol. 2012;107(10):1530–6.

    Article  Google Scholar 

  12. Dietz HP, Korda A. Which bowel symptoms are most strongly associated with a true rectocele? Aust N Z J Obstet Gynaecol. 2005;45(6):505–8.

    Article  Google Scholar 

  13. Dietz HP. Translabial ultrasound in the assessment of pelvic floor and anorectal function in women with defecatory disorders. Tech Coloproctol. 2014;18(5):481–94.

    Article  CAS  Google Scholar 

  14. Kruger JA, Heap SW, Murphy BA, et al. How best to measure the levator hiatus: evidence for the non-Euclidean nature of the 'plane of minimal dimensions'. Ultrasound Obstet Gynecol. 2010;36(6):755–8.

    Article  CAS  Google Scholar 

  15. Dietz H, Bernardo M, Kirby A, Shek K. Minimal criteria for the diagnosis of avulsion of the puborectalis muscle by tomographic ultrasound. Int Urogynecol J. 2010;22:699–704.

    Article  Google Scholar 

  16. Guzman Rojas R, Kamisan Atan I, Shek KL, et al. The prevalence of abnormal posterior compartment anatomy and its association with obstructed defecation symptoms in urogynecological patients. Int Urogynecol J. 2016;27(6):939–44.

    Article  Google Scholar 

  17. Hainsworth AJ, Pilkington SA, Grierson C, et al. Accuracy of integrated total pelvic floor ultrasound compared to defaecatory MRI in females with pelvic floor defaecatory dysfunction. Br J Radiol. 2016;89(1068):20160522.

    Article  Google Scholar 

  18. Simren M, Palsson OS, Whitehead WE. Update on Rome IV criteria for colorectal disorders: implications for clinical practice. Curr Gastroenterol Rep. 2017;19(4):15.

    Article  Google Scholar 

  19. Dietz HP, Clarke B. The influence of posture on perineal ultrasound imaging parameters. Int Urogynecol J Pelvic Floor Dysfunct. 2001;12(2):104–6.

    Article  CAS  Google Scholar 

  20. Braverman M, Kamisan Atan I, Turel F, et al. Does patient posture affect the ultrasound evaluation of pelvic organ prolapse? J Ultrasound Med. 2019;38(1):233–8.

    Article  Google Scholar 

  21. Bø K, Lilleås F, Talseth T, et al. Dynamic MRI of the pelvic floor muscles in an upright sitting position. Neurourol Urodyn. 2001;20(2):167–74.

    Article  Google Scholar 

  22. Heymen S, Scarlett Y, Jones K, et al. Randomized, controlled trial shows biofeedback to be superior to alternative treatments for patients with pelvic floor dyssynergia-type constipation. Dis Colon Rectum. 2007;50(4):428–41.

    Article  Google Scholar 

  23. Rao SS, Seaton K, Miller M, et al. Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol. 2007;5(3):331–8.

    Article  Google Scholar 

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Authors and Affiliations

  1. Pelvic Floor Unit, Monash Medical Centre, 246 Clayton Road, Clayton, VIC, Australia

    Jerome Melon

  2. Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia

    Moshe Gillor, Ka Lai Shek & Hans Peter Dietz

  3. Faculty of Medicine and Health Sciences, Rehabilitation Sciences and Physiotherapy, MOVANT, University of Antwerp, Antwerp, Belgium

    Hedwig Neels

  4. Gynaecology and Obstetrics, Antwerp University Hospital, Antwerp, Belgium

    Hedwig Neels

  5. Liverpool Clinical School, Western Sydney University, Liverpool, NSW, Australia

    Ka Lai Shek

Authors
  1. Jerome Melon
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  2. Moshe Gillor
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  3. Hedwig Neels
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  4. Ka Lai Shek
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  5. Hans Peter Dietz
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Contributions

J. Melon: project development, data collection, data management, manuscript writing/editing. M. Gillor: project development, data management, statistical analysis, manuscript writing/editing; H. Neels: project development, manuscript writing/editing. K.L. Shek: data management, statistical analysis, manuscript writing/editing. H.P. Dietz: project development, data management, statistical analysis, manuscript writing/editing.

Corresponding author

Correspondence to Jerome Melon.

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Financial disclaimers/conflicts of interest

J. Melon: nil; M. Gillor: nil; H. Neels: nil; K.L. Shek: received unrestricted educational grants from Mindray and travel support from GE Medical; H.P. Dietz: received lecture honoraria and travel assistance from GE Medical and Mindray.

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Melon, J., Gillor, M., Neels, H. et al. Persistent levator co-activation is not associated with symptoms or bother of obstructed defecation. Int Urogynecol J 31, 2611–2615 (2020). https://doi.org/10.1007/s00192-020-04389-z

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  • DOI: https://doi.org/10.1007/s00192-020-04389-z

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