Advertisement

Anorectal Physiology Testing

  • Ian M. Paquette
  • Joshua I. S. BleierEmail author
Chapter

Abstract

During the past several decades, anal physiology testing has afforded us a more complete understanding of the complex interactions between pelvic anatomy and physiology. Techniques have been improved and validated in both normal volunteers and in states of disease. This chapter will give a detailed overview of the differing methods of anal physiology testing and provide clinical correlations as to when these tests may be useful, or conversely, in which situations clinical judgment should supersede testing.

Keywords

Anal physiology Manometry Electromyography Defecography Pudendal nerve 

References

  1. 1.
    Amarenco G, Kerdraon J. Pudendal nerve terminal sensitive latency: technique and normal values. J Urol. 1999;161(1):103–6.PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Felt-Bersma RJ, Gort G, Meuwissen SG. Normal values in anal manometry and rectal sensation: a problem of range. Hepato-Gastroenterology. 1991;38(5):444–9.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Laudano MA, Chughtai B, Lee RK, Seklehner S, Elterman D, Kaplan SA, et al. Use of the bulbocavernosus reflex system in assessing voiding dysfunction. World J Urol. 2013;31(6):1459–62.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Granata G, Padua L, Rossi F, De Franco P, Coraci D, Rossi V. Electrophysiological study of the bulbocavernosus reflex: normative data. Funct Neurol. 2013;28(4):293–5.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Deffieux X, Raibaut P, Rene-Corail P, Katz R, Perrigot M, Ismael SS, et al. External anal sphincter contraction during cough: not a simple spinal reflex. Neurourol Urodyn. 2006;25(7):782–7.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Shafik A. Re: Cough anal reflex: strict relationship between intravesical pressure and pelvic floor muscle electromyographic activity during cough. Urodynamic and electrophysiological study. J Urol. 2005;174(4 Pt 1):1502–3. author reply 3.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Amarenco G, Ismael SS, Lagauche D, Raibaut P, Rene-Corail P, Wolff N, et al. Cough anal reflex: strict relationship between intravesical pressure and pelvic floor muscle electromyographic activity during cough. Urodynamic and electrophysiological study. J Urol. 2005;173(1):149–52.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Henry MM, Parks AG, Swash M. The anal reflex in idiopathic faecal incontinence: an electrophysiological study. Br J Surg. 1980;67(11):781–3.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Sangwan YP, Coller JA, Barrett RC, Murray JJ, Roberts PL, Schoetz DJ Jr. Prospective comparative study of abnormal distal rectoanal excitatory reflex, pudendal nerve terminal motor latency, and single fiber density as markers of pudendal neuropathy. Dis Colon Rectum. 1996;39(7):794–8.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Sangwan YP, Coller JA, Barrett RC, Murray JJ, Roberts PL, Schoetz DJ Jr. Distal rectoanal excitatory reflex: a reliable index of pudendal neuropathy? Dis Colon Rectum. 1995;38(9):916–20.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Guinet A, Verollet D, Deffontaines Rufin S, Sheikh Ismael S, Raibaut P, Amarenco G. Qualitative and quantitative analysis of rectoanal inhibitory reflex (RAIR) modulation in functional bowel disorders. Int J Color Dis. 2011;26(4):501–5.CrossRefGoogle Scholar
  12. 12.
    Xu X, Pasricha PJ, Sallam HS, Ma L, Chen JD. Clinical significance of quantitative assessment of rectoanal inhibitory reflex (RAIR) in patients with constipation. J Clin Gastroenterol. 2008;42(6):692–8.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Morais MB, Sdepanian VL, Tahan S, Goshima S, Soares AC, Motta ME, et al. Effectiveness of anorectal manometry using the balloon method to identify the inhibitory recto-anal reflex for diagnosis of Hirschsprung’s disease. Rev Assoc Med Bras. 2005;51(6):313–7. discussion 2.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Herman RM, Berho M, Murawski M, Nowakowski M, Rys J, Schwarz T, et al. Defining the histopathological changes induced by nonablative radiofrequency treatment of faecal incontinence—a blinded assessment in an animal model. Color Dis. 2015;17(5):433–40.CrossRefGoogle Scholar
  15. 15.
    Nikjooy A, Maroufi N, Ebrahimi Takamjani I, Hadizdeh Kharazi H, Mahjoubi B, Azizi R, et al. MR defecography: a diagnostic test for the evaluation of pelvic floor motion in patients with dyssynergic defecation after biofeedback therapy. Med J Islam Repub Iran. 2015;29:188.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Brandao AC, Ianez P. MR imaging of the pelvic floor: defecography. Magn Reson Imaging Clin N Am. 2013;21(2):427–45.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Heinrich H, Sauter M, Fox M, Weishaupt D, Halama M, Misselwitz B, et al. Assessment of obstructive defecation by high-resolution anorectal manometry compared with magnetic resonance defecography. Clin Gastroenterol Hepatol. 2015;13(7):1310–7.e1.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Carrington EV, Brokjaer A, Craven H, Zarate N, Horrocks EJ, Palit S, et al. Traditional measures of normal anal sphincter function using high-resolution anorectal manometry (HRAM) in 115 healthy volunteers. Neurogastroenterol Motil. 2014;26(5):625–35.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Schizas AM, Emmanuel AV, Williams AB. Anal canal vector volume manometry. Dis Colon Rectum. 2011;54(6):759–68.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Simpson RR, Kennedy ML, Nguyen MH, Dinning PG, Lubowski DZ. Anal manometry: a comparison of techniques. Dis Colon Rectum. 2006;49(7):1033–8.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Noelting J, Bharucha AE, Lake DS, Manduca A, Fletcher JG, Riederer SJ, et al. Semi-automated vectorial analysis of anorectal motion by magnetic resonance defecography in healthy subjects and fecal incontinence. Neurogastroenterol Motil. 2012;24(10):e467–75.PubMedPubMedCentralCrossRefGoogle Scholar
  22. 22.
    Nazir M, Carlsen E, Nesheim BI. Do occult anal sphincter injuries, vector volume manometry and delivery variables have any predictive value for bowel symptoms after first time vaginal delivery without third and fourth degree rupture? A prospective study. Acta Obstet Gynecol Scand. 2002;81(8):720–6.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Kroesen AJ. Extended anal sphincter assessment by vector manometry. Int J Color Dis. 2000;15(5–6):311–2.CrossRefGoogle Scholar
  24. 24.
    Zbar AP, Kmiot WA, Aslam M, Williams A, Hider A, Audisio RA, et al. Use of vector volume manometry and endoanal magnetic resonance imaging in the adult female for assessment of anal sphincter dysfunction. Dis Colon Rectum. 1999;42(11):1411–8.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Yang YK, Wexner SD. Anal pressure vectography is of no apparent benefit for sphincter evaluation. Int J Color Dis. 1994;9(2):92–5.CrossRefGoogle Scholar
  26. 26.
    Vitton V, Ben Hadj Amor W, Baumstarck K, Behr M, Bouvier M, Grimaud JC. Comparison of three-dimensional high-resolution manometry and endoanal ultrasound in the diagnosis of anal sphincter defects. Color Dis. 2013;15(10):e607–11.CrossRefGoogle Scholar
  27. 27.
    Lee TH, Lee JS. High-resolution anorectal manometry and anal endosonographic findings in the evaluation of fecal incontinence. J Neurogastroenterol Motil. 2012;18(4):450–1.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Gourcerol G, Granier S, Bridoux V, Menard JF, Ducrotte P, Leroi AM. Do endoflip assessments of anal sphincter distensibility provide more information on patients with fecal incontinence than high-resolution anal manometry? Neurogastroenterol Motil. 2016;28(3):399–409.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Felt-Bersma RJ, Meuwissen SG. Anal manometry. Int J Color Dis. 1990;5(3):170–3.CrossRefGoogle Scholar
  30. 30.
    Dreznik Z, Bat L. Value of anal manometry in anorectal diseases. Harefuah. 1989;117(7–8):196–8.PubMedGoogle Scholar
  31. 31.
    Kuypers JH. Anal manometry, its applications and indications. Neth J Surg. 1982;34(4):153–8.PubMedGoogle Scholar
  32. 32.
    Frenckner B, Euler CV. Influence of pudendal block on the function of the anal sphincters. Gut. 1975;16(6):482–9.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Lestar B, Penninckx F, Kerremans R. The composition of anal basal pressure. An in vivo and in vitro study in man. Int J Color Dis. 1989;4(2):118–22.CrossRefGoogle Scholar
  34. 34.
    Wexner SD. Re: Manometric tests of anorectal function in the management of defecation disorders. Am J Gastroenterol. 1997;92(8):1400.PubMedGoogle Scholar
  35. 35.
    Nivatvongs S, Stern HS, Fryd DS. The length of the anal canal. Dis Colon Rectum. 1981;24(8):600–1.PubMedCrossRefGoogle Scholar
  36. 36.
    Rajasekaran MR, Jiang Y, Bhargava V, Lieber RL, Mittal RK. Novel applications of external anal sphincter muscle sarcomere length to enhance the anal canal function. Neurogastroenterol Motil. 2011;23(1):70–5.e7.PubMedCrossRefGoogle Scholar
  37. 37.
    Rajasekaran MR, Jiang Y, Bhargava V, Littlefield R, Lee A, Lieber RL, et al. Length-tension relationship of the external anal sphincter muscle: implications for the anal canal function. Am J Physiol Gastrointest Liver Physiol. 2008;295(2):G367–73.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Seong MK. Clinical utility of balloon expulsion test for functional defecation disorders. Ann Surg Treat Res. 2016;90(2):89–94.PubMedCrossRefGoogle Scholar
  39. 39.
    Beck DE. A simplified balloon expulsion test. Dis Colon Rectum. 1992;35:597–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Kassis NC, Wo JM, James-Stevenson TN, Maglinte DD, Heit MH, Hale DS. Balloon expulsion testing for the diagnosis of dyssynergic defecation in women with chronic constipation. Int Urogynecol J. 2015;26(9):1385–90.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Minguez M, Herreros B, Sanchiz V, Hernandez V, Almela P, Anon R, et al. Predictive value of the balloon expulsion test for excluding the diagnosis of pelvic floor dyssynergia in constipation. Gastroenterology. 2004;126(1):57–62.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Fleshman JW, Dreznik Z, Cohen E, Fry RD, Kodner IJ. Balloon expulsion test facilitates diagnosis of pelvic floor outlet obstruction due to nonrelaxing puborectalis muscle. Dis Colon Rectum. 1992;35(11):1019–25.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Barnes PR, Lennard-Jones JE. Balloon expulsion from the rectum in constipation of different types. Gut. 1985;26(10):1049–52.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Cescon C, Riva D, Zacesta V, Drusany-Staric K, Martsidis K, Protsepko O, et al. Effect of vaginal delivery on the external anal sphincter muscle innervation pattern evaluated by multichannel surface EMG: results of the multicentre study TASI-2. Int Urogynecol J. 2014;25(11):1491–9.PubMedCrossRefPubMedCentralGoogle Scholar
  45. 45.
    Thomas C, Lefaucheur JP, Galula G, de Parades V, Bourguignon J, Atienza P. Respective value of pudendal nerve terminal motor latency and anal sphincter electromyography in neurogenic fecal incontinence. Neurophysiol Clin. 2002;32(1):85–90.PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    Neill ME, Swash M. Increased motor unit fibre density in the external anal sphincter muscle in ano-rectal incontinence: a single fibre EMG study. J Neurol Neurosurg Psychiatry. 1980;43(4):343–7.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Penninckx F, Kerremans R. Objective evaluation of anorectal function in fecal incontinence. Acta Chir Belg. 1985;85(5):335–40.PubMedPubMedCentralGoogle Scholar
  48. 48.
    Parks AG, Swash M, Urich H. Sphincter denervation in anorectal incontinence and rectal prolapse. Gut. 1977;18(8):656–65.PubMedPubMedCentralCrossRefGoogle Scholar
  49. 49.
    Cheong DM, Vaccaro CA, Salanga VD, Wexner SD, Phillips RC, Hanson MR, et al. Electrodiagnostic evaluation of fecal incontinence. Muscle Nerve. 1995;18(6):612–9.PubMedCrossRefPubMedCentralGoogle Scholar
  50. 50.
    Mellgren A, editor. Physiologic testing. New York: Springer; 2011.Google Scholar
  51. 51.
    Glia A, Gylin M, Gullberg K, Lindberg G. Biofeedback retraining in patients with functional constipation and paradoxical puborectalis contraction: comparison of anal manometry and sphincter electromyography for feedback. Dis Colon Rectum. 1997;40(8):889–95.PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Rutter KR. Electromyographic changes in certain pelvic floor abnormalities. Proc R Soc Med. 1974;67(1):53–6.PubMedPubMedCentralGoogle Scholar
  53. 53.
    Rutter KR, Riddell RH. The solitary ulcer syndrome of the rectum. Clin Gastroenterol. 1975;4(3):505–30.PubMedPubMedCentralGoogle Scholar
  54. 54.
    Wiesner A, Jost WH. EMG of the external anal sphincter: needle is superior to surface electrode. Dis Colon Rectum. 2000;43(1):116–8.PubMedCrossRefPubMedCentralGoogle Scholar
  55. 55.
    Podnar S, Vodusek DB. Standardisation of anal sphincter EMG: high and low threshold motor units. Clin Neurophysiol. 1999;110(8):1488–91.PubMedCrossRefPubMedCentralGoogle Scholar
  56. 56.
    Podnar S, Rodi Z, Lukanovic A, Trsinar B, Vodusek DB. Standardization of anal sphincter EMG: technique of needle examination. Muscle Nerve. 1999;22(3):400–3.PubMedCrossRefPubMedCentralGoogle Scholar
  57. 57.
    Binnie NR, Kawimbe BM, Papachrysostomou M, Clare N, Smith AN. The importance of the orientation of the electrode plates in recording the external anal sphincter EMG by non-invasive anal plug electrodes. Int J Color Dis. 1991;6(1):5–8.CrossRefGoogle Scholar
  58. 58.
    Claes G. EMG study of the external anal sphincter: current diagnostic aids. Acta Belg Med Phys. 1990;13(2):79–83.PubMedPubMedCentralGoogle Scholar
  59. 59.
    Strijers RL, Felt-Bersma RJ, Visser SL, Meuwissen SG. Anal sphincter EMG in anorectal disorders. Electromyogr Clin Neurophysiol. 1989;29(7–8):405–8.PubMedPubMedCentralGoogle Scholar
  60. 60.
    Enck P, von Giesen HJ, Schafer A, Heyer T, Gantke B, Flesch S, et al. Comparison of anal sonography with conventional needle electromyography in the evaluation of anal sphincter defects. Am J Gastroenterol. 1996;91(12):2539–43.PubMedPubMedCentralGoogle Scholar
  61. 61.
    Law PJ, Kamm MA, Bartram CI. A comparison between electromyography and anal endosonography in mapping external anal sphincter defects. Dis Colon Rectum. 1990;33(5):370–3.PubMedCrossRefPubMedCentralGoogle Scholar
  62. 62.
    Tjandra JJ, Milsom JW, Schroeder T, Fazio VW. Endoluminal ultrasound is preferable to electromyography in mapping anal sphincteric defects. Dis Colon Rectum. 1993;36(7):689–92.PubMedCrossRefPubMedCentralGoogle Scholar
  63. 63.
    Cescon C, Mesin L, Nowakowski M, Merletti R. Geometry assessment of anal sphincter muscle based on monopolar multichannel surface EMG signals. J Electromyogr Kinesiol. 2011;21(2):394–401.PubMedCrossRefPubMedCentralGoogle Scholar
  64. 64.
    Gregory WT, Clark AL, Simmons K, Lou JS. Determining the shape of the turns-amplitude cloud during anal sphincter quantitative EMG. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(7):971–6.PubMedPubMedCentralCrossRefGoogle Scholar
  65. 65.
    Merletti R, Bottin A, Cescon C, Farina D, Gazzoni M, Martina S, et al. Multichannel surface EMG for the non-invasive assessment of the anal sphincter muscle. Digestion. 2004;69(2):112–22.PubMedCrossRefPubMedCentralGoogle Scholar
  66. 66.
    Preston DM, Lennard-Jones JE. Anismus in chronic constipation. Dig Dis Sci. 1985;30(5):413–8.PubMedCrossRefPubMedCentralGoogle Scholar
  67. 67.
    Jorge JM, Wexner SD, Ger GC, Salanga VD, Nogueras JJ, Jagelman DG. Cinedefecography and electromyography in the diagnosis of nonrelaxing puborectalis syndrome. Dis Colon Rectum. 1993;36(7):668–76.PubMedCrossRefPubMedCentralGoogle Scholar
  68. 68.
    Jones PN, Lubowski DZ, Swash M, Henry MM. Is paradoxical contraction of puborectalis muscle of functional importance? Dis Colon Rectum. 1987;30(9):667–70.PubMedCrossRefPubMedCentralGoogle Scholar
  69. 69.
    Womack NR, Williams NS, Holmfield JH, Morrison JF, Simpkins KC. New method for the dynamic assessment of anorectal function in constipation. Br J Surg. 1985;72(12):994–8.PubMedCrossRefPubMedCentralGoogle Scholar
  70. 70.
    Suzuki H, Matsumoto K, Amano S, Fujioka M, Honzumi M. Anorectal pressure and rectal compliance after low anterior resection. Br J Surg. 1980;67(9):655–7.PubMedCrossRefPubMedCentralGoogle Scholar
  71. 71.
    Varma JS, Smith AN, Busuttil A. Correlation of clinical and manometric abnormalities of rectal function following chronic radiation injury. Br J Surg. 1985;72(11):875–8.PubMedCrossRefGoogle Scholar
  72. 72.
    Suzuki H, Fujioka M. Rectal pressure and rectal compliance in ulcerative colitis. Jpn J Surg. 1982;12(1):79–81.PubMedCrossRefPubMedCentralGoogle Scholar
  73. 73.
    Bregendahl S, Emmertsen KJ, Lous J, Laurberg S. Bowel dysfunction after low anterior resection with and without neoadjuvant therapy for rectal cancer: a population-based cross-sectional study. Color Dis. 2013;15(9):1130–9.Google Scholar
  74. 74.
    Emmertsen KJ, Laurberg S. Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer. Ann Surg. 2012;255(5):922–8.PubMedCrossRefPubMedCentralGoogle Scholar
  75. 75.
    Bajwa A, Thiruppathy K, Emmanuel A. The utility of conditioning sequences in barostat protocols for the measurement of rectal compliance. Color Dis. 2013;15(6):715–8.CrossRefGoogle Scholar
  76. 76.
    Felt-Bersma RJ, Sloots CE, Poen AC, Cuesta MA, Meuwissen SG. Rectal compliance as a routine measurement: extreme volumes have direct clinical impact and normal volumes exclude rectum as a problem. Dis Colon Rectum. 2000;43(12):1732–8.PubMedCrossRefPubMedCentralGoogle Scholar
  77. 77.
    Rasmussen OO, Ronholt C, Alstrup N, Christiansen J. Anorectal pressure gradient and rectal compliance in fecal incontinence. Int J Color Dis. 1998;13(4):157–9.CrossRefGoogle Scholar
  78. 78.
    Fox M, Thumshirn M, Fried M, Schwizer W. Barostat measurement of rectal compliance and capacity. Dis Colon Rectum. 2006;49(3):360–70.PubMedCrossRefPubMedCentralGoogle Scholar
  79. 79.
    Krogh K, Ryhammer AM, Lundby L, Gregersen H, Laurberg TS. Comparison of methods used for measurement of rectal compliance. Dis Colon Rectum. 2001;44(2):199–206.PubMedCrossRefPubMedCentralGoogle Scholar
  80. 80.
    Madoff RD, Orrom WJ, Rothenberger DA, Goldberg SM. Rectal compliance: a critical reappraisal. Int J Color Dis. 1990;5(1):37–40.CrossRefGoogle Scholar
  81. 81.
    Awad RA, Camacho S, Flores F, Altamirano E, Garcia MA. Rectal tone and compliance affected in patients with fecal incontinence after fistulotomy. World J Gastroenterol. 2015;21(13):4000–5.PubMedPubMedCentralCrossRefGoogle Scholar
  82. 82.
    Gang Y. What is the desirable stimulus to induce the rectoanal inhibitory reflex? Dis Colon Rectum. 1995;38(1):60–3.PubMedCrossRefPubMedCentralGoogle Scholar
  83. 83.
    Yin S, Zhao K. Research progress of rectoanal inhibitory reflex. Zhonghua Wei Chang Wai Ke Za Zhi. 2015;18(12):1284–7.PubMedPubMedCentralGoogle Scholar
  84. 84.
    de Lorijn F, de Jonge WJ, Wedel T, Vanderwinden JM, Benninga MA, Boeckxstaens GE. Interstitial cells of Cajal are involved in the afferent limb of the rectoanal inhibitory reflex. Gut. 2005;54(8):1107–13.PubMedPubMedCentralCrossRefGoogle Scholar
  85. 85.
    Rattan S, Sarkar A, Chakder S. Nitric oxide pathway in rectoanal inhibitory reflex of opossum internal anal sphincter. Gastroenterology. 1992;103(1):43–50.PubMedCrossRefPubMedCentralGoogle Scholar
  86. 86.
    Zbar AP, Jonnalagadda R. Parameters of the rectoanal inhibitory reflex in different anorectal disorders. Dis Colon Rectum. 2003;46(4):557. author reply -8.PubMedCrossRefPubMedCentralGoogle Scholar
  87. 87.
    Carmona JA, Ortiz H, Perez-Cabanas I. Alterations in anorectal function after anterior resection for cancer of the rectum. Int J Color Dis. 1991;6(2):108–10.CrossRefGoogle Scholar
  88. 88.
    Bozkurt MA, Kocatas A, Surek A, Kankaya B, Kalayci MU, Alis H. The importance of defecography in the assessment of the etiology of chronic constipation: an analysis of 630 patients. Ulus Cerrahi Derg. 2014;30(4):183–5.PubMedPubMedCentralGoogle Scholar
  89. 89.
    Peznanski AK. The use of a semisolid contrast medium in a defecography. Radiology. 1970;97(1):82.PubMedCrossRefPubMedCentralGoogle Scholar
  90. 90.
    Ikenberry S, Lappas JC, Hana MP, Rex DK. Defecography in healthy subjects: comparison of three contrast media. Radiology. 1996;201(1):233–8.PubMedCrossRefPubMedCentralGoogle Scholar
  91. 91.
    Goei R. Defecography: principles of technique and interpretation. Radiologe. 1993;33(6):356–60.PubMedPubMedCentralGoogle Scholar
  92. 92.
    Altringer WE, Saclarides TJ, Dominguez JM, Brubaker LT, Smith CS. Four-contrast defecography: pelvic “floor-oscopy”. Dis Colon Rectum. 1995;38(7):695–9.PubMedCrossRefPubMedCentralGoogle Scholar
  93. 93.
    Saclarides TJ, Brubaker LT, Altringer WE, Smith CS, Dominguez JM. Clarifying the technique of four-contrast defecography. Dis Colon Rectum. 1996;39(7):826.PubMedCrossRefPubMedCentralGoogle Scholar
  94. 94.
    Bremmer S, Mellgren A, Holmstrom B, Lopez A, Uden R. Peritoneocele: visualization with defecography and peritoneography performed simultaneously. Radiology. 1997;202(2):373–7.PubMedCrossRefPubMedCentralGoogle Scholar
  95. 95.
    Bremmer S, Ahlback SO, Uden R, Mellgren A. Simultaneous defecography and peritoneography in defecation disorders. Dis Colon Rectum. 1995;38(9):969–73.PubMedCrossRefPubMedCentralGoogle Scholar
  96. 96.
    Faccioli N, Comai A, Mainardi P, Perandini S, Moore F, Pozzi-Mucelli R. Defecography: a practical approach. Diagn Interv Radiol. 2010;16(3):209–16.PubMedPubMedCentralGoogle Scholar
  97. 97.
    Low VH, Ho LM, Freed KS. Vaginal opacification during defecography: direction of vaginal migration aids in diagnosis of pelvic floor pathology. Abdom Imaging. 1999;24(6):565–8.PubMedCrossRefPubMedCentralGoogle Scholar
  98. 98.
    Ho LM, Low VH, Freed KS. Vaginal opacification during defecography: utility of placing a folded gauze square at the introitus. Abdom Imaging. 1999;24(6):562–4.PubMedCrossRefPubMedCentralGoogle Scholar
  99. 99.
    Kim AY. How to interpret a functional or motility test—defecography. J Neurogastroenterol Motil. 2011;17(4):416–20.PubMedPubMedCentralCrossRefGoogle Scholar
  100. 100.
    Brennan D, Williams G, Kruskal J. Practical performance of defecography for the evaluation of constipation and incontinence. Semin Ultrasound CT MR. 2008;29(6):420–6.PubMedCrossRefPubMedCentralGoogle Scholar
  101. 101.
    Mellgren A, Bremmer S, Johansson C, Dolk A, Uden R, Ahlback SO, et al. Defecography. Results of investigations in 2,816 patients. Dis Colon Rectum. 1994;37(11):1133–41.PubMedCrossRefPubMedCentralGoogle Scholar
  102. 102.
    Poon FW, Lauder JC, Finlay IG. Technical report: evacuating proctography—a simplified technique. Clin Radiol. 1991;44(2):113–6.PubMedCrossRefPubMedCentralGoogle Scholar
  103. 103.
    Mellgren A, Bremmer S. Defecography and its clinical significance. Increased use of an “old” technique. Lakartidningen. 1995;92(47):4416–21.PubMedPubMedCentralGoogle Scholar
  104. 104.
    Jorge JM, Ger GC, Gonzalez L, Wexner SD. Patient position during cinedefecography. Influence on perineal descent and other measurements. Dis Colon Rectum. 1994;37(9):927–31.PubMedCrossRefPubMedCentralGoogle Scholar
  105. 105.
    Henry MM, Parks AG, Swash M. The pelvic floor musculature in the descending perineum syndrome. Br J Surg. 1982;69(8):470–2.PubMedCrossRefGoogle Scholar
  106. 106.
    Parks AG, Porter NH, Hardcastle J. The syndrome of the descending perineum. Proc R Soc Med. 1966;59(6):477–82.PubMedPubMedCentralGoogle Scholar
  107. 107.
    Shorvon PJ, McHugh S, Diamant NE, Somers S, Stevenson GW. Defecography in normal volunteers: results and implications. Gut. 1989;30(12):1737–49.PubMedPubMedCentralCrossRefGoogle Scholar
  108. 108.
    Chen HH, Iroatulam A, Alabaz O, Weiss EG, Nogueras JJ, Wexner SD. Associations of defecography and physiologic findings in male patients with rectocele. Tech Coloproctol. 2001;5(3):157–61.PubMedCrossRefPubMedCentralGoogle Scholar
  109. 109.
    Delemarre JB, Kruyt RH, Doornbos J, Buyze-Westerweel M, Trimbos JB, Hermans J, et al. Anterior rectocele: assessment with radiographic defecography, dynamic magnetic resonance imaging, and physical examination. Dis Colon Rectum. 1994;37(3):249–59.PubMedCrossRefPubMedCentralGoogle Scholar
  110. 110.
    Kaiser A, Buchmann P, Bruhlmann W. The value of defecography for diagnosis of rectocele and rectal prolapse. Helv Chir Acta. 1994;60(5):697–700.PubMedPubMedCentralGoogle Scholar
  111. 111.
    Piloni V, Pomerri F, Platania E, Pieri L, Pinto F, Gasparini G, et al. The National Workshop on Defecography: anorectal deformities with a functional origin (prolapse, intussusception, rectocele). Radiol Med. 1994;87(6):789–95.PubMedPubMedCentralGoogle Scholar
  112. 112.
    Soares FA, Regadas FS, Murad-Regadas SM, Rodrigues LV, Silva FR, Escalante RD, et al. Role of age, bowel function and parity on anorectocele pathogenesis according to cinedefecography and anal manometry evaluation. Color Dis. 2009;11(9):947–50.CrossRefGoogle Scholar
  113. 113.
    van Dam JH, Ginai AZ, Gosselink MJ, Huisman WM, Bonjer HJ, Hop WC, et al. Role of defecography in predicting clinical outcome of rectocele repair. Dis Colon Rectum. 1997;40(2):201–7.PubMedCrossRefPubMedCentralGoogle Scholar
  114. 114.
    Thapar RB, Patankar RV, Kamat RD, Thapar RR, Chemburkar V. MR defecography for obstructed defecation syndrome. Indian J Radiol Imaging. 2015;25(1):25–30.PubMedPubMedCentralCrossRefGoogle Scholar
  115. 115.
    Reginelli A, Di Grezia G, Gatta G, Iacobellis F, Rossi C, Giganti M, et al. Role of conventional radiology and MRi defecography of pelvic floor hernias. BMC Surg. 2013;13(Suppl 2):S53.PubMedPubMedCentralCrossRefGoogle Scholar
  116. 116.
    Piloni V, Tosi P, Vernelli M. MR-defecography in obstructed defecation syndrome (ODS): technique, diagnostic criteria and grading. Tech Coloproctol. 2013;17(5):501–10.PubMedCrossRefPubMedCentralGoogle Scholar
  117. 117.
    Cappabianca S, Reginelli A, Iacobellis F, Granata V, Urciuoli L, Alabiso ME, et al. Dynamic MRI defecography vs. entero-colpo-cysto-defecography in the evaluation of midline pelvic floor hernias in female pelvic floor disorders. Int J Color Dis. 2011;26(9):1191–6.CrossRefGoogle Scholar
  118. 118.
    Mortele KJ, Fairhurst J. Dynamic MR defecography of the posterior compartment: indications, techniques and MRI features. Eur J Radiol. 2007;61(3):462–72.PubMedCrossRefPubMedCentralGoogle Scholar
  119. 119.
    Hetzer FH, Andreisek G, Tsagari C, Sahrbacher U, Weishaupt D. MR defecography in patients with fecal incontinence: imaging findings and their effect on surgical management. Radiology. 2006;240(2):449–57.PubMedCrossRefGoogle Scholar
  120. 120.
    Roos JE, Weishaupt D, Wildermuth S, Willmann JK, Marincek B, Hilfiker PR. Experience of 4 years with open MR defecography: pictorial review of anorectal anatomy and disease. Radiographics. 2002;22(4):817–32.PubMedCrossRefPubMedCentralGoogle Scholar
  121. 121.
    Paetzel C, Strotzer M, Furst A, Rentsch M, Lenhart M, Feuerbach S. Dynamic MR defecography for diagnosis of combined functional disorders of the pelvic floor in proctology. Rofo. 2001;173(5):410–5.PubMedCrossRefPubMedCentralGoogle Scholar
  122. 122.
    Hilfiker PR, Debatin JF, Schwizer W, Schoenenberger AW, Fried M, Marincek B. MR defecography: depiction of anorectal anatomy and pathology. J Comput Assist Tomogr. 1998;22(5):749–55.PubMedCrossRefPubMedCentralGoogle Scholar
  123. 123.
    Vitton V, Vignally P, Barthet M, Cohen V, Durieux O, Bouvier M, et al. Dynamic anal endosonography and MRI defecography in diagnosis of pelvic floor disorders: comparison with conventional defecography. Dis Colon Rectum. 2011;54(11):1398–404.PubMedCrossRefPubMedCentralGoogle Scholar
  124. 124.
    Pradal-Prat D, Mares P, Peray P, Lopez S, Gagnard-Landra C. Pudendal nerve motor latency correlation by age and sex. Electromyogr Clin Neurophysiol. 1998;38(8):491–6.PubMedPubMedCentralGoogle Scholar
  125. 125.
    Laurberg S, Swash M. Effects of aging on the anorectal sphincters and their innervation. Dis Colon Rectum. 1989;32(9):737–42.PubMedCrossRefPubMedCentralGoogle Scholar
  126. 126.
    Vernava AM 3rd, Longo WE, Daniel GL. Pudendal neuropathy and the importance of EMG evaluation of fecal incontinence. Dis Colon Rectum. 1993;36(1):23–7.PubMedCrossRefPubMedCentralGoogle Scholar
  127. 127.
    Vaccaro CA, Cheong DM, Wexner SD, Nogueras JJ, Salanga VD, Hanson MR, et al. Pudendal neuropathy in evacuatory disorders. Dis Colon Rectum. 1995;38(2):166–71.PubMedCrossRefPubMedCentralGoogle Scholar
  128. 128.
    Loganathan A, Schloithe AC, Hakendorf P, Liyanage CM, Costa M, Wattchow D. Prolonged pudendal nerve terminal motor latency is associated with decreased resting and squeeze pressures in the intact anal sphincter. Color Dis. 2013;15(11):1410–5.CrossRefGoogle Scholar
  129. 129.
    Suilleabhain CB, Horgan AF, McEnroe L, Poon FW, Anderson JH, Finlay IG, et al. The relationship of pudendal nerve terminal motor latency to squeeze pressure in patients with idiopathic fecal incontinence. Dis Colon Rectum. 2001;44(5):666–71.PubMedCrossRefPubMedCentralGoogle Scholar
  130. 130.
    Chen AS, Luchtefeld MA, Senagore AJ, Mackeigan JM, Hoyt C. Pudendal nerve latency. Does it predict outcome of anal sphincter repair? Dis Colon Rectum. 1998;41(8):1005–9.PubMedCrossRefPubMedCentralGoogle Scholar
  131. 131.
    Vaccaro CA, Cheong DM, Wexner SD, Salanga VD, Phillips RC, Hanson MR. Role of pudendal nerve terminal motor latency assessment in constipated patients. Dis Colon Rectum. 1994;37(12):1250–4.PubMedCrossRefPubMedCentralGoogle Scholar
  132. 132.
    Lubowski DZ, Swash M, Nicholls RJ, Henry MM. Increase in pudendal nerve terminal motor latency with defaecation straining. Br J Surg. 1988;75(11):1095–7.PubMedCrossRefPubMedCentralGoogle Scholar
  133. 133.
    Rakas P, Liapis A, Karandreas A, Creatsas G. Pudendal nerve terminal motor latency in women with genuine stress incontinence and prolapse. Gynecol Obstet Investig. 2001;51(3):187–90.CrossRefGoogle Scholar
  134. 134.
    Pfeifer J, Salanga VD, Agachan F, Weiss EG, Wexner SD. Variation in pudendal nerve terminal motor latency according to disease. Dis Colon Rectum. 1997;40(1):79–83.PubMedCrossRefPubMedCentralGoogle Scholar
  135. 135.
    Birnbaum EH, Stamm L, Rafferty JF, Fry RD, Kodner IJ, Fleshman JW. Pudendal nerve terminal motor latency influences surgical outcome in treatment of rectal prolapse. Dis Colon Rectum. 1996;39(11):1215–21.PubMedCrossRefPubMedCentralGoogle Scholar
  136. 136.
    Tomita R, Igarashi S, Ikeda T, Koshinaga T, Fujisaki S, Tanjoh K. Pudendal nerve terminal motor latency in patients with or without soiling 5 years or more after low anterior resection for lower rectal cancer. World J Surg. 2007;31(2):403–8.PubMedCrossRefPubMedCentralGoogle Scholar
  137. 137.
    Matsuoka H, Masaki T, Sugiyama M, Atomi Y. Pudendal nerve terminal motor latency in evaluation of evacuatory disorder following low anterior resection for rectal carcinoma. Hepato-Gastroenterology. 2007;54(77):1426–9.PubMedPubMedCentralGoogle Scholar
  138. 138.
    Lim JF, Tjandra JJ, Hiscock R, Chao MW, Gibbs P. Preoperative chemoradiation for rectal cancer causes prolonged pudendal nerve terminal motor latency. Dis Colon Rectum. 2006;49(1):12–9.PubMedCrossRefPubMedCentralGoogle Scholar
  139. 139.
    Snooks SJ, Setchell M, Swash M, Henry MM. Injury to innervation of pelvic floor sphincter musculature in childbirth. Lancet. 1984;2(8402):546–50.PubMedCrossRefPubMedCentralGoogle Scholar
  140. 140.
    Wexner SD, Marchetti F, Salanga VD, Corredor C, Jagelman DG. Neurophysiologic assessment of the anal sphincters. Dis Colon Rectum. 1991;34(7):606–12.PubMedCrossRefPubMedCentralGoogle Scholar
  141. 141.
    Lefaucheur J, Yiou R, Thomas C. Pudendal nerve terminal motor latency: age effects and technical considerations. Clin Neurophysiol. 2001;112(3):472–6.PubMedCrossRefPubMedCentralGoogle Scholar
  142. 142.
    Tam PK. Hirschsprung’s disease: a bridge for science and surgery. J Pediatr Surg. 2016;51(1):18–22.PubMedCrossRefPubMedCentralGoogle Scholar
  143. 143.
    Zuelzer WW, Wilson JL. Functional intestinal obstruction on a congenital neurogenic basis in infancy. Am J Dis Child. 1948;75(1):40–64.PubMedPubMedCentralGoogle Scholar
  144. 144.
    Whitehouse FR, Kernohan JW. Myenteric plexus in congenital megacolon; study of 11 cases. Arch Intern Med (Chic). 1948;82(1):75–111.CrossRefGoogle Scholar
  145. 145.
    Tang YF, Chen JG, An HJ, Jin P, Yang L, Dai ZF, et al. High-resolution anorectal manometry in newborns: normative values and diagnostic utility in Hirschsprung disease. Neurogastroenterol Motil. 2014;26(11):1565–72.PubMedCrossRefPubMedCentralGoogle Scholar
  146. 146.
    Martellucci J. Low anterior resection syndrome: a treatment algorithm. Dis Colon Rectum. 2016;59(1):79–82.PubMedCrossRefPubMedCentralGoogle Scholar
  147. 147.
    Carrillo A, Enriquez-Navascues JM, Rodriguez A, Placer C, Mugica JA, Saralegui Y, et al. Incidence and characterization of the anterior resection syndrome through the use of the LARS scale (low anterior resection score). Cir Esp. 2016;94(3):137–43.PubMedCrossRefPubMedCentralGoogle Scholar
  148. 148.
    Hou XT, Pang D, Lu Q, Yang P, Jin SL, Zhou YJ, et al. Validation of the Chinese version of the low anterior resection syndrome score for measuring bowel dysfunction after sphincter-preserving surgery among rectal cancer patients. Eur J Oncol Nurs. 2015;19(5):495–501.PubMedCrossRefPubMedCentralGoogle Scholar
  149. 149.
    Samalavicius NE, Dulskas A, Lasinskas M, Smailyte G. Validity and reliability of a Lithuanian version of low anterior resection syndrome score. Tech Coloproctol. 2016;20:215–20.PubMedCrossRefPubMedCentralGoogle Scholar
  150. 150.
    O'Riordain MG, Molloy RG, Gillen P, Horgan A, Kirwan WO. Rectoanal inhibitory reflex following low stapled anterior resection of the rectum. Dis Colon Rectum. 1992;35(9):874–8.PubMedCrossRefPubMedCentralGoogle Scholar
  151. 151.
    Bleier JI, Maykel JA. Outcomes following proctectomy. Surg Clin North Am. 2013;93(1):89–106.PubMedCrossRefPubMedCentralGoogle Scholar
  152. 152.
    Podzemny V, Pescatori LC, Pescatori M. Management of obstructed defecation. World J Gastroenterol. 2015;21(4):1053–60.PubMedPubMedCentralCrossRefGoogle Scholar
  153. 153.
    Mathers SE, Kempster PA, Swash M, Lees AJ. Constipation and paradoxical puborectalis contraction in anismus and Parkinson’s disease: a dystonic phenomenon? J Neurol Neurosurg Psychiatry. 1988;51(12):1503–7.PubMedPubMedCentralCrossRefGoogle Scholar
  154. 154.
    Kuijpers HC, Bleijenberg G. The spastic pelvic floor syndrome. A cause of constipation. Dis Colon Rectum. 1985;28(9):669–72.PubMedCrossRefPubMedCentralGoogle Scholar
  155. 155.
    Kuijpers HC, Bleijenberg G, de Morree H. The spastic pelvic floor syndrome. Large bowel outlet obstruction caused by pelvic floor dysfunction: a radiological study. Int J Color Dis. 1986;1(1):44–8.CrossRefGoogle Scholar
  156. 156.
    MacDonald A, Shearer M, Paterson PJ, Finlay IG. Relationship between outlet obstruction constipation and obstructed urinary flow. Br J Surg. 1991;78(6):693–5.PubMedCrossRefPubMedCentralGoogle Scholar
  157. 157.
    Heymen S, Wexner SD, Gulledge AD. MMPI assessment of patients with functional bowel disorders. Dis Colon Rectum. 1993;36(6):593–6.PubMedCrossRefGoogle Scholar
  158. 158.
    Sullivan ES, Leaverton GH, Hardwick CE. Transrectal perineal repair: an adjunct to improved function after anorectal surgery. Dis Colon Rectum. 1968;11(2):106–14.PubMedCrossRefGoogle Scholar
  159. 159.
    Khubchandani IT, Sheets JA, Stasik JJ, Hakki AR. Endorectal repair of rectocele. Dis Colon Rectum. 1983;26(12):792–6.PubMedCrossRefGoogle Scholar
  160. 160.
    Sehapayak S. Transrectal repair of rectocele: an extended armamentarium of colorectal surgeons. A report of 355 cases. Dis Colon Rectum. 1985;28(6):422–33.PubMedCrossRefGoogle Scholar
  161. 161.
    Picirillo MTT, Yoon K, Patino Paul R, Lucas J, Wexner S. Rectoceles: the incidence and clinical significance. Tech Coloproctol. 1996;2:75–9.Google Scholar
  162. 162.
    Block IR. Transrectal repair of rectocele using obliterative suture. Dis Colon Rectum. 1986;29(11):707–11.PubMedCrossRefPubMedCentralGoogle Scholar
  163. 163.
    Karasick S, Karasick D, Karasick SR. Functional disorders of the anus and rectum: findings on defecography. AJR Am J Roentgenol. 1993;160(4):777–82.PubMedCrossRefGoogle Scholar
  164. 164.
    Siproudhis L, Ropert A, Lucas J, Raoul JL, Heresbach D, Bretagne JF, et al. Defecatory disorders, anorectal and pelvic floor dysfunction: a polygamy? Radiologic and manometric studies in 41 patients. Int J Color Dis. 1992;7(2):102–7.CrossRefGoogle Scholar
  165. 165.
    Karlbom U, Graf W, Nilsson S, Pahlman L. Does surgical repair of a rectocele improve rectal emptying? Dis Colon Rectum. 1996;39(11):1296–302.PubMedCrossRefPubMedCentralGoogle Scholar
  166. 166.
    Hawksworth W, Roux JP. Vaginal hysterectomy. J Obstet Gynaecol Br Emp. 1958;65(2):214–28.PubMedCrossRefPubMedCentralGoogle Scholar
  167. 167.
    Jorge JM, Yang YK, Wexner SD. Incidence and clinical significance of sigmoidoceles as determined by a new classification system. Dis Colon Rectum. 1994;37(11):1112–7.PubMedCrossRefPubMedCentralGoogle Scholar
  168. 168.
    Jorge JM, Wexner SD, Ehrenpreis ED, Nogueras JJ, Jagelman DG. Does perineal descent correlate with pudendal neuropathy? Dis Colon Rectum. 1993;36(5):475–83.PubMedCrossRefPubMedCentralGoogle Scholar
  169. 169.
    Barisic GI, Krivokapic ZV, Markovic VA, Popovic MA. Outcome of overlapping anal sphincter repair after 3 months and after a mean of 80 months. Int J Color Dis. 2006;21(1):52–6.CrossRefGoogle Scholar
  170. 170.
    Gilliland R, Altomare DF, Moreira H Jr, Oliveira L, Gilliland JE, Wexner SD. Pudendal neuropathy is predictive of failure following anterior overlapping sphincteroplasty. Dis Colon Rectum. 1998;41(12):1516–22.PubMedCrossRefPubMedCentralGoogle Scholar
  171. 171.
    Londono-Schimmer EE, Garcia-Duperly R, Nicholls RJ, Ritchie JK, Hawley PR, Thomson JP. Overlapping anal sphincter repair for faecal incontinence due to sphincter trauma: five year follow-up functional results. Int J Color Dis. 1994;9(2):110–3.CrossRefGoogle Scholar
  172. 172.
    Bravo Gutierrez A, Madoff RD, Lowry AC, Parker SC, Buie WD, Baxter NN. Long-term results of anterior sphincteroplasty. Dis Colon Rectum. 2004;47(5):727–31. discussion 31–2PubMedCrossRefPubMedCentralGoogle Scholar
  173. 173.
    Karoui S, Leroi AM, Koning E, Menard JF, Michot F, Denis P. Results of sphincteroplasty in 86 patients with anal incontinence. Dis Colon Rectum. 2000;43(6):813–20.PubMedCrossRefPubMedCentralGoogle Scholar
  174. 174.
    Malouf AJ, Norton CS, Engel AF, Nicholls RJ, Kamm MA. Long-term results of overlapping anterior anal-sphincter repair for obstetric trauma. Lancet. 2000;355(9200):260–5.PubMedCrossRefPubMedCentralGoogle Scholar
  175. 175.
    Ratto C, Litta F, Parello A, Donisi L, De Simone V, Zaccone G. Sacral nerve stimulation in faecal incontinence associated with an anal sphincter lesion: a systematic review. Color Dis. 2012;14(6):e297–304.CrossRefGoogle Scholar
  176. 176.
    Johnson BL 3rd, Abodeely A, Ferguson MA, Davis BR, Rafferty JF, Paquette IM. Is sacral neuromodulation here to stay? Clinical outcomes of a new treatment for fecal incontinence. J Gastrointest Surg. 2015;19(1):15–9. discussion 9–20.PubMedCrossRefPubMedCentralGoogle Scholar
  177. 177.
    Hull T, Giese C, Wexner SD, Mellgren A, Devroede G, Madoff RD, et al. Long-term durability of sacral nerve stimulation therapy for chronic fecal incontinence. Dis Colon Rectum. 2013;56(2):234–45.PubMedCrossRefPubMedCentralGoogle Scholar
  178. 178.
    Quezada Y, Whiteside JL, Rice T, Karram M, Rafferty JF, Paquette IM. Does preoperative anal physiology testing or ultrasonography predict clinical outcome with sacral neuromodulation for fecal incontinence? Int Urogynecol J. 2015;26(11):1613–7.PubMedPubMedCentralCrossRefGoogle Scholar
  179. 179.
    Brouwer R, Duthie G. Sacral nerve neuromodulation is effective treatment for fecal incontinence in the presence of a sphincter defect, pudendal neuropathy, or previous sphincter repair. Dis Colon Rectum. 2010;53(3):273–8.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Colon and Rectal SurgeryUniversity of Cincinnati College of Medicine, Christ Hospital Center for Pelvic Floor DisordersCincinnatiUSA
  2. 2.Department of SurgeryUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaUSA

Personalised recommendations