Abstract
Background
The aim of this prospective study was to evaluate the relationship between the pathogenesis of anorectocele and the anatomy of the anal canal and anorectal junction using echodefecography.
Methods
The study was conducted on a total of 100 women with obstructed defecation, mean age 46.6 years, who underwent echodefecography. Patients were classified based on rectocele status into group I, without rectocele (n = 32); group II, grade I rectocele (n = 11); group III, grade II (n = 27); and group IV, grade III (n = 30). We identified the layers of the anterior anorectal wall and measured anterior external sphincter length, posterior external sphincter and puborectalis length, gap between anterior external sphincter and anorectal junction, anorectal wall thickness in 3 locations: (1) proximal to anterior external anal sphincter; (2) anterior anorectal junction; (3) 1.0 cm proximal to anorectal junction.
Results
The anterior part of the external anal sphincter was significantly longer in group I (18.91 ± 0.38 mm) than in group III (16.94 ± 0.45 mm) (p < 0.05), and the length in group I was similar to that in group II (18.56 ± 0.44 mm) (p = 0.6223). The gap was significantly shorter in group I (21.24 ± 0.97 mm) than in group III (25.04 ± 0.82 mm) and group IV (23.82 ± 0.80 mm) (p < 0.05). The length of the anterior part of the external anal sphincter as a percentage of the length of the posterior external anal sphincter together with the puborectalis muscle was a mean of 57.39 ± 2.13% in group I, 56.01 ± 1.581% in group II, 47.77 ± 1.48% in group III, and 50.45 ± 1.61% in group IV, with a significantly higher percentage in group I than in groups III (p = 0.0126) and IV (p = 0.0007). No significant differences were identified between any of the groups regarding anorectal wall thickness at any of the 3 selected locations (p > 0.05). The muscularis propria layer of the rectal wall was not identified in 2 patients in group I (6.25%), 3 patients in group II (11.11%), and 3 patients in group III (10.00%), and 6 in group IV (8.82%), with no significant differences among groups.
Conclusions
The pathogenesis of anorectocele may be associated with a shorter anterior part of the external anal sphincter and consequently a longer gap.
Similar content being viewed by others
References
Golf BH (1931) An histologic study of the perivaginal fascia in a nullipara. Surg Gynecol Obstet 52:32–42
Nicholls DH, Milley PM (1970) Surgical significance of the rectovaginal septum. Am J Obstet Gynecol 108:215–220
Ricci JV, Thom CH (1954) The myth of a surgically useful fascia in vaginal plastic reconstructions. Rev Surg Obstet Gynecol 11:253–261
Uhlenhuth E, Nolley GW (1957) Vaginal fascia, a myth? Obstet Gynecol 10:349–358
DeLancey JO (1992) Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol 166:1717–1728
Regadas FS, Murad-Regadas SM, Lima DM et al (2007) Anal canal anatomy showed by three-dimensional anorectal ultrasonography. Surg Endosc 21:2207–2211
Richardson AC (1993) The rectovaginal septum revisited: its relationship to rectocele and its important in rectocele repair. Clin Obstet Gynecol 36:976–983
Regadas FS, Haas EM, Abbas MA et al (2011) Prospective multicenter trial comparing echodefecography with defecography in the assessment of anorectal dysfunction in patients with obstructed defecation. Dis Colon Rectum 54:686–692
Regadas SMM, Regadas FSP, Rodrigues LV (2005) Importância do ultra-som tridimensional na avaliação anorretal. Arq Gastroenterol 42:226–232
Agachan F, Chen T, Pfeiffer J, Wexner SD (1996) A constipation scoring system to simplify evaluation and management of constipated patients. Dis Colon Rectum 39:681–685
Murad-Regadas SM, Regadas FS, Rodrigues LR et al (2007) A novel procedure to assess anismus using three-dimensional dynamic anal ultrasonography. Colorectal Dis 9:159–165
Murad-Regadas SM, Regadas FS, Rodrigues LV, Silva FR, Soares FA, Escalante RD (2008) A novel three-dimensional dynamic anorectal ultrasonography technique (echodefecography) to assess obstructed defecation, a comparison with defecography. Surg Endosc 22:974–979
Ludwikowski B, Hayward IO, Fritsch HJ (2002) Rectovaginal fascia: an important structure in pelvic visceral surgery ? About its development, structure, and function. Pediatr Surg 37:634–638
Aigner F, Zbar AP, Ludwikowski B, Kreczy A, Kovacs P, Fritsch H (2004) The rectogenital septum: morphology, function, and clinical relevance. Dis Colon Rectum 47:131–140
Dietz HP, Franco AV, Shek KL, Kirby A (2011) Avulsion injury and levator hiatal ballooning: two independent risk factors for prolapsed? An observational study. Acta Obstet Gynecol Scand (in press)
Barthet M, Portier F, Heyries L (2000) Dynamic anal endosonography may challenge defecography for assessing dynamic anorectal disorders: results of a prospective pilot study. Endoscopy 32:300–305
Beer-Gabel M, Teshler M, Barzilai N (2000) Dynamic transperineal ultrasound (DTP-US) a new method for diagnosis of pelvic floor disorders: technical details and preliminary results. Dis Colon Rectum 45:239–248
Dietz H, Beer-Gabel M (2011) Ultrasound in the investigation of posterior compartment vaginal prolapse and obstructed defecation. Ultrasound Obstet Gynecol (in press)
Regadas FS, Murad-Regadas SM, Wexner SD et al (2007) Anorectal three-dimensional endosonography and anal manometry in assessing anterior rectocele in women. A new pathogenesis concept and the basic surgical principle. Colorectal Dis 9:80–85
Shafik A, El-Sibai O, Shafik AA (2003) On the pathogenesis of rectocele: the concept of the rectovaginal pressure gradient. Int Urogynecol J Pelvic Floor Dysfunct 14:310–315
Stecco C, Macchi V, Porzionato A et al (2005) Histotopographic study of the rectovaginal septum. Ital J Anat Embryol 110:247–254
Frudinger A, Halligan S, Bartram CI, Spencer JA, Kamm MA (1999) Changes in anal anatomy following vaginal delivery revealed by anal endosonography. Br J Obstet Gynaecol 106:233–237
Soares FA, Regadas FS, Murad-Regadas SM et al (2009) Role of age, bowel function and parity on rectocele pathogenesis according to cinedefecography and anal manometry evaluation. Colorectal Dis 11:947–950
Murad-Regadas SM, Peterson TV, Pinto RA, Regadas FS, Sands DR, Wexner SD (2009) Defecographic pelvic floor abnormalities in constipated patients: does mode of delivery matter? Tech Coloproctol 13:279–283
Murad-Regadas SM, Regadas FS (2006) Ultra-sonografia anorretal dinâmica: novas técnicas. In: Disturbios Funcionais do Assoalho Pélvico. Rio de janeiro, Revinter, 79–94
Murad-Regadas SM, Regadas FS, Rodrigues LV et al (2006) Ecodefecografia tridimensional dinâmica. Nova técnica para avaliação da síndrome da defecação obstruída (SDO). Rev Bras Colo-proctol 26:168–177
Conflict of interest
The authors declare that no conflict of interest exists.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Regadas, F.S.P., Lima Barreto, R.G., Murad-Regadas, S.M. et al. Correlation between anorectocele with the anterior anal canal and anorectal junction anatomy using echodefecography. Tech Coloproctol 16, 133–138 (2012). https://doi.org/10.1007/s10151-012-0805-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10151-012-0805-x