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A comparison of dynamic transperineal ultrasound (DTP-US) with dynamic evacuation proctography (DEP) in the diagnosis of cul de sac hernia (enterocele) in patients with evacuatory dysfunction

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International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Background/Aims

Cul-de-sac hernias (enterocele and peritoneocele) are difficult to diagnose in patients presenting with primary evacuatory difficulty. Failure to recognize their presence in patients undergoing surgery may lead to poor functional outcome. Accurate diagnosis requires specialized investigation including dynamic evacuation proctography (DEP) or dynamic magnetic resonance (MR) imaging. Recently, dynamic transperineal ultrasonography (DTP-US) has been used for this purpose. This study compares DEP with DTP-US for the diagnosis of cul-de-sac hernias in those patients presenting with evacuatory dysfunction.

Materials and methods

Sixty-two female patients with chronically obstructed defecation underwent blinded clinical, DEP, and DTP-US assessment to define the accuracy of diagnosis of cul-de-sac hernias.

Results

Both the DEP and the DTP-US techniques show concordance for the diagnosis of cul-de-sac hernias in an unselected patient cohort. Patients in both groups have the same duration of constipation with a greater likelihood of prior hysterectomy in those with cul-de-sac hernias. The diagnosis was established separately by DEP in 88% and in 82% of the cases by DTP-US. Transperineal sonography is discordant with DEP in 45% of cases once the diagnosis of cul-de-sac hernia is made, over the contents of the hernia and over the degree of transvaginal enterocele descent, where DTP-US tends to upgrade enterocele severity. Both techniques confirm the high incidence of concomitant pelvic floor compartment pathology.

Conclusions

Both methods have accuracy for the diagnosis of cul-de-sac hernias in those patients presenting with evacuatory difficulty. Transperineal sonography tends to more readily diagnose peritoneocele and to upgrade enterocele extent. As an office procedure, it is a valuable adjunct to the clinical examination in the diagnosis of cul-de-sac hernia.

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References

  1. Ranney B (1981) Enterocele, vaginal prolapse, pelvic hernia: recognition and treatment. Am J Obstet Gynecol 140:53–60

    PubMed  CAS  Google Scholar 

  2. Addison WA, Timmons MC, Wall L, Livengood CH (1989) Failed abdominal sacral colpopexy: observations and recommendations. Obstet Gynecol 74(3 Pt 2):480–483

    PubMed  CAS  Google Scholar 

  3. Berman L, Aversa J, Abir F, Longo WE (2006) Management of disorders of the posterior pelvic floor. J Gastroenterol 41:802–806

    Article  Google Scholar 

  4. Takahashi T, Yamana T, Sahara R, Iwadare J (2006) Enterocele: what is the clinical implication. Dis Colon Rectum 49(10 Suppl):S75–S81

    Article  PubMed  Google Scholar 

  5. Nichols DH, Randall CL (1996) Enterocele. In: Nichols DH (ed) Vaginal Surgery. Williams & Wilkins, Baltimore, pp 319–320

    Google Scholar 

  6. Kelvin FM, Maglinte DD, Hornback JA, Benson JT (1992) Pelvic prolapse: assessment with evacuation proctography. Radiology 184:547–551

    PubMed  CAS  Google Scholar 

  7. Rotholtz NA, Efron JE, Weiss EG, Nogueras JJ, Wexner SD (2002) Anal manometric predictors of significant rectocele in constipated patients. Techn Coloproctol 6:73–77

    Article  CAS  Google Scholar 

  8. Brubaker L, Retzky S, Smith C (1993) Pelvic floor evaluation with dynamic fluoroscopy. Obstet Gynecol 82:863–868

    PubMed  CAS  Google Scholar 

  9. Lienemann A, Anthuber C, Baron A, Reiser M (2000) Diagnosing enteroceles using dynamic magnetic resonance imaging. Dis Colon Rectum 43:205–213

    Article  PubMed  CAS  Google Scholar 

  10. Bremmer S, Mellgren A, Holmstrom B, Lopez A, Uden R (1997) Peritoneocele: vizualisation with defecography and peritoneography performed simultaneously. Radiology 202:373–377

    PubMed  CAS  Google Scholar 

  11. Sentovich SM, Rivela LJ, Thorson AG, Christensen MA, Blatchford GJ (1995) Simultaneous dynamic proctography and peritoneography for pelvic floor disorders. Dis Colon Rectum 38:969–973

    Article  Google Scholar 

  12. Goei R, Kemerink G (1990) Radiation dose in defecography. Radiology 176:137–139

    PubMed  CAS  Google Scholar 

  13. Lienemann A, Anthuber C, Baron A, Reiser M (1997) Dynamic MR colpocystorectography assessing pelvic floor descent. Eur Radiol 87:1309–1317

    Article  Google Scholar 

  14. Torricelli P, Pecchi A, Caruso Lombardi A, Vetruccio E, Vetruccio S, Romagnoli R (2002) Magnetic resonance imaging in evaluating functional disorders of female pelvic floor. Radiol Med (Torino) 103(5–6):488–500

    CAS  Google Scholar 

  15. Beer-Gabel M, Teshler M, Barzilai N, Lurie Y, Malnick S, Bass D, Zbar A (2002) Dynamic transperineal ultrasound in the diagnosis of pelvic floor disorders: pilot study. Dis Colon Rectum 45:239–248

    Article  PubMed  Google Scholar 

  16. Beer-Gabel M, Teshler M, Schechtman E, Zbar A (2004) Dynamic transperineal ultrasound vs. defecography in patients with evacuatory difficulty: a pilot study. Int J Colorectal Dis 19:60–67

    Article  PubMed  CAS  Google Scholar 

  17. Thompson WG, Longstreth G, Drossman DA, Heaton K, Irvine EJ, Muller-Lissner S (2000) Functional bowel disorders and functional abdominal pain. In: Drossman DA, Corrazziari E, Talley NJ, Thompson WG, Whitehead WE (eds) Rome II: the functional gastrointestinal disorders, 2nd edn. Degnon Associates, McLean, VA, USA, pp 351–432

    Google Scholar 

  18. Shorvon PJ, McHugh S, Diamant NE, Somers S, Stevenson GW (1989) Defecography in normal volunteers: results and implications. Gut 30:1737–1749

    Article  PubMed  CAS  Google Scholar 

  19. Beer-Gabel M, Zbar AP (2002) Dynamic transperineal ultrasonography (DTP-US) in patients presenting with obstructed defecation. Tech Coloproctol 6:141

    Article  Google Scholar 

  20. DeLancey JOL (1992) Anatomic aspects of vaginal eversion after hysterectomy. AmJ Obstet Gynecol 166(6 Pt 1):1717–1728

    CAS  Google Scholar 

  21. Jorge JM, Yang YK, Wexner SD (1994) Incidence and clinical significance of sigmoidoceles as determined by a new classification system. Dis Colon Rectum 37(11):1112–1127 Nov

    Article  PubMed  CAS  Google Scholar 

  22. Zbar AP, Lienemann A, Fritsch H, Beer-Gabel M, Pescatori M (2003) Rectocele: pathogenesis and surgical management. Int J Colorectal Dis 18:369–384

    Article  PubMed  CAS  Google Scholar 

  23. van Dam JH, Hop WCJ, Schouten WR (2000) Analysis of patients with poor outcome of rectocele repair. Dis Colon Rectum 43:1556–1560

    Article  PubMed  Google Scholar 

  24. Chou Q, Weber AM, Piedmonte MR (2000) Clinical presentation of enterocele. Obstet Gynecol 96:599–603

    Article  PubMed  CAS  Google Scholar 

  25. Saclarides TJ, Brubaker L (2005) Evacuatory dysfunction following gynecologic surgery. In: Wexner SD, Zbar AP, Pescatori M (eds) Complex anorectal disorders. Springer-Verlag, London, pp 532–545

    Chapter  Google Scholar 

  26. Cruickshank SH (1991) Sacrospinous fixation—should this be performed at the time of vaginal hysterectomy. Am J Obstet Gynecol 164:1072–1076

    Google Scholar 

  27. McCall ML (1997) Posterior culdoplasty: surgical correction of enterocele during vaginal hysterectomy. A preliminary report. Obstet Gynecol 10:596–602

    Google Scholar 

  28. Backer MH (1992) Success with sacrospinous suspension of the prolapsed vaginal vault. Surg Gynecol Obstet 175:419–420

    PubMed  Google Scholar 

  29. Jorge JM, Ger GC, Gonzales L, Wexner SD (1994) Patient position during cinedefecography: influence on perineal descent and other measurements. Dis Colon Rectum 37:927–931

    Article  PubMed  CAS  Google Scholar 

  30. Dietz HP, Clarke B (2001) The influence of posture on perineal ultrasound imaging parameters. Int Urogynecol J Pelvic Floor Dysfunct 12:104–106

    Article  PubMed  CAS  Google Scholar 

  31. Mouritsen L, Bach (1994) Ultrasonic evaluation of bladder neck position and mobility: the influence of urethral catheter, bladder volume, and body position. Neurourol Urodyn 13:637–646

    Article  PubMed  CAS  Google Scholar 

  32. Schaer GN, Koechli OR, Schuessler B, Haller U (1996) Perineal ultrasound: determination of reliable examination procedures. Ultrasound Obstet Gynecol 7:347–352

    Article  PubMed  CAS  Google Scholar 

  33. Fielding JR, Griffiths DJ, Versi E, Mulkern RV, Lee ML, Jolesz FA (1998) MR imaging of pelvic floor continence mechanisms in the supine and sitting positions. Am J Roentgenol (AJR) 171:1607–1610

    CAS  Google Scholar 

  34. Mouritsen L, Strandberg C (1994) Vaginal ultrasonography versus colpo-cysto-urethrography in the evaluation of female urinary incontinence. Acta Obstet Gynecol Scand 73:338–342 Apr

    Article  PubMed  CAS  Google Scholar 

  35. Bertschinger KM, Hetzer FH, Roos JE, Treiber K, Marincek B, Hilfiker PR (2002) Dynamic MR imaging of the pelvic floor performed with patient sitting in an open-magnet unit versus with patient supine in a closed-magnet unit. Radiology 223:501–508

    Article  PubMed  Google Scholar 

  36. Bremmer S, Mellgren A, Holmstrom B, Uden R (1997) Pelvic anatomy and pathology is influenced by distention of the rectum: defecoperitoneography before and after rectal filling with contrast medium. Dis Colon Rectum 40:1477–1483

    Article  PubMed  CAS  Google Scholar 

  37. Kelvin FM, Maglinte DD, Hale DS, Benson JT (2000) Female pelvic organ prolapse: a comparison of triphasic dynamic MR imaging and triphasic fluoroscopic cystocolpoproctography. Am J Roentgenol (AJR) 174:81–88

    CAS  Google Scholar 

  38. Halligan S, Bartram S, Hall C, Wingate J (1996) Enterocele revealed by simultaneous evacuation proctography and peritoneography: does “defecation block” exist. Am J Roentgenol (AJR) 167:461–466

    CAS  Google Scholar 

  39. 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

    Article  PubMed  Google Scholar 

  40. Karaus M, Neuhaus P, Wiedenmann TB (2000) Diagnosis of enteroceles by dynamic anorectal endosonography. Dis Colon Rectum 43:1683–1688

    Article  PubMed  CAS  Google Scholar 

  41. Vierhout ME, van PD (2002) Diagnosis of posterior enterocele: comparison of rectal ultrasonography with intraoperative diagnosis. J Ultrasound Med 21:383–387

    PubMed  Google Scholar 

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Acknowledgments

We thank Pr. AP Zbar for his critical review and Liat Kvodi for her help.

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Authors and Affiliations

  1. Department Gastroenterology, Chaim Sheba Medical Center, Tel Hashomer, 52621, Israel

    M. Beer-Gabel, Y. Assoulin & E. Bardan

  2. Department of Radiology, Chaim Sheba Medical Center, Tel-Hashomer, 52621, Israel

    M. Amitai

  3. Sackler School of Medicine, Tel- Aviv University, Tel Aviv, Israel

    M. Beer-Gabel & E. Bardan

Authors
  1. M. Beer-Gabel
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  2. Y. Assoulin
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  3. M. Amitai
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  4. E. Bardan
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Correspondence to M. Beer-Gabel.

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Beer-Gabel, M., Assoulin, Y., Amitai, M. et al. A comparison of dynamic transperineal ultrasound (DTP-US) with dynamic evacuation proctography (DEP) in the diagnosis of cul de sac hernia (enterocele) in patients with evacuatory dysfunction. Int J Colorectal Dis 23, 513–519 (2008). https://doi.org/10.1007/s00384-008-0440-1

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