Can Puborectalis Muscle and Abdominal Subcutaneous Adipose Tissue Thickness Indicate Dyssynergic Defecation?

Yıl 2024, Cilt: 5 Sayı: 3, 168 - 173, 30.09.2024

Eren Çamur , Dilek Acar

https://doi.org/10.56766/ntms.1492600

Öz

Introduction: Chronic constipation (CC) is a common issue in primary care and gastroenterology. Defined variably by patients and clinicians, CC per Rome III criteria requires symptoms for six months, present three or more days per month for three months. Dyssynergic defecation (DD), a functional constipation type, involves the failure of pelvic floor muscles to relax during defecation. This study examines the relationship between DD, puborectalis muscle thickness, and subcutaneous adipose tissue thickness via MR defecography.
Material and Method: After ethical approval, MR defecography images of 110 patients from Ankara Bilkent City Hospital were analyzed retrospectively. Exclusions included pelvic floor descensus, rectal mass, cystocele, rectocele, or movement artifacts. The study comprised 52 DD patients and 52 matched controls. Measurements of subcutaneous adipose tissue at L5-S1 and puborectalis muscle thickness were performed on T2-weighted images.
Results: DD patients had significantly higher abdominal subcutaneous adipose tissue and puborectalis muscle thickness than controls (p=0.021, p=0.001). No significant gender differences were noted. ROC analysis revealed cut-off values of 23 mm for adipose tissue and 4.8 mm for puborectalis muscle thickness. Positive predictive values for DD were 62% for adipose tissue >23 mm, 74% for puborectalis muscle thickness >4.8 mm, and 90% for both criteria.
Discussion: MR defecography is essential for diagnosing DD. This study is the first to investigate the link between DD and puborectalis muscle thickness. Increased abdominal subcutaneous adipose tissue suggests a connection between DD and obesity, possibly due to increased intra-abdominal pressure leading to higher puborectalis muscle tone.
Conclusion: Puborectalis muscle thickness >4.8 mm and abdominal subcutaneous adipose tissue thickness >23 mm are key parameters for diagnosing DD in MR defecography. These findings underscore the importance of MR defecography in diagnosing and understanding DD, leading to more precise and individualized treatments.

Anahtar Kelimeler

puborectalis, pelvic floor, defecation, constipation, adipose

Kaynakça

• Bharucha AE, Dorn SD, Lembo A, Pressman A. American gastroenterological association medical position statement on constipation. Gastroenterol. 2013; 144(1):211-17.
• Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional Bowel Disorders. Gastroenterol. 2006; 130(5):1480-91.
• Sadeghi A, Akbarpour E, Majidirad F, et al. Dyssynergic Defecation: A Comprehensive Review on Diagnosis and Management. Turkish Journal of Gastroenterol. 2023; 34(3):182-95.
• Preston DM, Lennard-Jones JE. Anismus in chronic constipation. Dig Dis Sci. 1985; 30(5):413-18.
• Colaiacomo MC, Masselli G, Polettini E, et al. Dynamic MR Imaging of the Pelvic Floor: a Pictorial Review1. Radiographics. 2019; 29(3):1-42.
• Vriesman MH, Koppen IJN, Camilleri M, Di Lorenzo C, Benninga MA. Management of functional constipation in children and adults. Nat Rev Gastroenterol Hepatol. 2020; 17(1):21-39.
• Salvador JC, Coutinho MP, Venâncio JM, Viamonte B. Dynamic magnetic resonance imaging of the female pelvic floor-a pictorial review. Insights Imaging. 2019; 10(1):4.
• Khatri G, de Leon AD, Lockhart ME. MR Imaging of the Pelvic Floor. Magn Reson Imaging Clin N Am. 2017; 25(3):457-80.
• Haliloglu N, Erden A. Magnetic resonance defecography findings of dyssynergic defecation. Pol J Radiol. 2022; 87(1):e181.
• Halligan S, Malouf A, Bartram CI, et al. Predictive Value of Impaired Evacuation at Proctography in Diagnosing Anismus. AJR Am J Roentgenol. 2012; 177(3):633-36.
• DeLancey JO. The anatomy of the pelvic floor. Curr Opin Obstet Gynecol. 1994; 6(4):313-16.
• Piloni V, Bergamasco M, Melara G, Garavello P. The clinical value of magnetic resonance defecography in males with obstructed defecation syndrome. Tech Coloproctol. 2018; 22(3):179-90.
• Chu WCW, Tam YH, Lam WWM, Ng AWH, Sit F, Yeung CK. Dynamic MR assessment of the anorectal angle and puborectalis muscle in pediatric patients with anismus: Technique and feasibility. JMRI. 2007; 25(5):1067-72.
• Voderholzer WA, Neuhaus DA, Klauser AG, Tzavella K, Müller-Lissner SA, Schindlbeck NE. Paradoxical sphincter contraction is rarely indicative of anismus. Gut. 1997; 41(2):258.
• Reiner CS, Tutuian R, Solopova AE, Pohl D, Marincek B, Weishaupt D. MR defecography in patients with dyssynergic defecation: spectrum of
• Çamur E and Acar D. imaging findings and diagnostic value. Br J Radiol. 2011; 84(998):136.
• Pisano U, Irvine L, Szczachor J, Jawad A, MacLeod A, Lim M. Anismus, Physiology, Radiology: Is It Time for Some Pragmatism? A Comparative Study of Radiological and Anorectal Physiology Findings in Patients With Anismus. Ann Coloproctol. 2016; 32(5):170.
• Lalwani N, El Sayed RF, Kamath A, Lewis S, Arif H, Chernyak V. Imaging and clinical assessment of functional defecatory disorders with emphasis on defecography. Abdom Radiol. 2021; 46(4):1323-33.
• 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 Disease1. Radiographics. 2002; 22(4):817-32.
• Kudish BI, Iglesia CB, Sokol RJ, et al. Effect of Weight Change on Natural History of Pelvic Organ Prolapse. Obstet Gynecol. 2009; 113(1):81.
• Wasserberg N, Haney M, Petrone P, et al. Morbid obesity adversely impacts pelvic floor function in females seeking attention for weight loss surgery. Dis Colon Rectum. 2007; 50(12):2096-103.
• Otunctemur A, Dursun M, Ozbek E, et al. Impact of metabolic syndrome on stress urinary incontinence in pre- and postmenopausal women. Int Urol Nephrol. 2014; 46(8):1501-505.