3rd International Congress On Pelvic Floor Disorders (2)

Cairo (Egypt) March 14-17, 2001

International Pelvic Floor Dysfunction Society

 
(26) Incontinence and Quality of Life in Male Patients with an Orthotopic Ileal Neobladder
Is there A Place for Physiotherapy?

M Van Kampen, H. Van Poppel, L. Baert, M De Waele, R Lysens Faculty of Physical Education and Physiotherapy, Division of Urology, University Hospital, Gasthuisberg, K.U.Leuven, Belgium 

Objectives: The aim of this study was to investigate incontinence and quality of life in men
with orthotopic bladder substitution for bladder cancer who were treated with physiotherapy.
Methods: The subject group consisted of 25 male consecutive patients who had undergone bladder
substitution. The patients took part in a pelvic floor reducation program for as long as they were
incontinent. Results about incontinence were evaluated at 3 months interval the first year postoperatively. Results about quality of life were gathered by a telephonic questionnaire (of Mansson ea). 
Results: Of the 25 patients, 3 died within the first year because of tumor progression. Incontinence during the day persisted in 48% of the cohort at one month post operative. Twenty-four, twelve, and eight percent of the patients remained incontinent at respectively three, six, and twelve months follow-up. Quality of life was good, only 10% of the patients was disturbed with their voiding pattern. 
Conclusions: The favourable results of continence and quality of life in comparison with other studies, where physiotherapy was not used, would suggest that there may be a place for this
therapy. 

(27) The Perineal Comeback 

Gibbone C ; Garofalo A. ; Longo F. Perineal & Uroginecological Unit A.S.L.8, Nichelino, Italy

In the past few years research has renewed it’s interest on the pelvic floor importance.
It’s very important to inform and correctly prepare women on the value of these muscles during her life and especially during parturition. Our objective was to have women recognize and
voluntarily contract and relax these muscles; pregnant women during the 20o week of gestation were invited to participate in a private 20-30 minute long session during which we evaluated the strength and duration of the perineal plane contractions as well as her ability to deliberately relax and contract specific muscles. In this way we believe it’s possible to obtain, with
personalized treatment, improved compliance during birth. Up to now, we have treated 65 firs-time expectant mothers with satisfying results. Furthermore, after birth, the women participate in follow up treatment to reacquire necessary tone to maintain pelvic static and prevent prolapse and incontinence. 

  (28) Perineal Pain 

GarofaloA. ; Gibbone C. ; Sibona S. Perineal & Uroginecological Unit A.S.L. 8 , Nichelino,
Italy

It’s very important to recognize the etiopathogenesis of perineal pain and , in particular, of pain with origins of a musculo tendineo nature. The latter, in fact, is responsible for an altered motor pattern in many cases generating incontinence and compromised sexuality. Eventual pathological alterations to the pelvic organs are excluded by means of clinical and/or instrumental tests.
Through adequate musculo-tendineo symptomology, it is possible to localize pain and consequent mechanical dysfunction. Approximately one third of the patients who enter our day hospital with perineal problems (urinary, sexual, fecal or lumbosacral) suffer considerable musculo-tendineo pain. In these cases it’s essential to eliminate the pain before initiating a reabilitative therapy.
Otherwise, according to our statistics, a percentage of unsuccessful rehabilitative therapies may be
attributed to analgesic inhibition.

(29) Sexual Dysfunction in Circumcised Females

Abou Bakr M. El Nashar Benha University Hospital 

Purpose: To determine the rate & degree of circumcision among a sample of newly married females & to compare between circumcised & noncircumcised females regarding sexual dysfunction. Setting Benha University Hospital, Maternal & child health centers & obstetric gynecological private clinics 
Methods: 264 newly married women were randomly selected. Data were collected using interviewing questionnaire format, symptoms check gynaecological examination.
Results: The circumcised group constitutes 75.8% of the sample. The most common degree was the 2nd degree representing 61%. Dysparunia (40.5% versus 18.8%), loss of libido (28.5% versus 15.6%), husband unsatisfaction (17.5% versus 4.7%), wifem unsatisfaction (43% versus 10.9%), occasional satisfaction or often but no orgasm (17.5% versus 25%) & always satisfaction & often orgasm (34% versus 39.1%) were reported by the circumcised & non-circumcised females respectively. Dysparunia (24.4% versus 50.8%), loss of libido (19.2% versus 34.4%), husband unsatisfaction (7.7% versus 23.8%), wife unsatisfaction (23.1% versus 55.7%), occasional satisfaction or often but no orgasm (25.6% versus 12.3%) & always satisfaction & often orgasm (43.6% versus 28.7%) were reported by the 1st degree & 2nd degree circumcised. 
Conclusion: Sexual dysfunction disorders are statistically higher in circumcised than in
non-circumcised females & statistically higher in 2nd degree than 1st degree circumcised females.

(30) Perineological cure of female stress urinary incontinence. The sub-urethral support: Experience with 600 cases performed over a 15 year period.

Jack Mouchel M.D. Le Mans France 

Groupement Europeen de Perineologie 

Since 1985, 600 cases of female stress urinary incontinence were treated with a suburethral support technique (SUS). 
Principles and Results : This technique entails placing under the middle urethra a mini-patch of  synthetic tissue (mainly Gore-Tex) the ends of which are then fastened to the anterior portion of the white line or more recently to the outer areas of the pubic arcuate ligament.
Based on anatomic logic similar to the one that led Ulmsten to develop the TVT, the SUS is predicated on the same physiologic principles. In this personal series of 600 cases performed over a
15 year period, the failure rate is 9.9% at 1 year , de 8.4% at 5 years, and 12.5% at 10 years. Long term outcomes are due, in our opinion, to the precision of the anatomo-physiological approach, the rigor of the indications (selection of strict stress incontinence cases) and the use of synthetic tissue capable of effectively replacing over the long term the deficient suburethral conjunctive tissue.
Complications: In this series, no serious general or visceral complication was observed. Prosthetic
material rejection occurred in 2% of cases. In all cases, extrusion was done towards the vagina.
Urinary continence was maintendespite rejection in 70% of cases. Compared to the TVT, the SUS, in addition to the benefit from using only one sling of synthetic tissue 15 times smaller, has the advantage of being performed under constant visual control at the expense of a minor suburethral dissection, which, at best, is only slightly bigger. Without a blind dimension to the procedure, it shows respect for the Retzius space and its vessels in addition to be virtually void of any bladder risk. 
Conclusion : Now that the anatomo-physiologic principles that justify the use of suburethral support procedures (TVT, SUS) are commonly accepted, the cost,
simplicity, and safety of the SUS would warrant closer and better consideration to the extent that this procedure has demonstrated its efficacy over time.

(30) From Urogynecology to Perineology

Jack Mouchel MD Groupement Europeen de Perineologie, Le Mans, France

Urogynecology, focused on urinary complaints and genital prolapse, has lost all interest in genito-sexual complaints and those related to the colorectal tract (dyschesia, anal incontinence). The anatomical approach, based on imaging and electrophysiological techniques, bridges the (anatomical and functional) gap between the different regions. It enables to explain and understand the incidence of combined disorders (urinary, colorectal, and sexual) and to understand the iatrogenic consequences of procedures, like colposuspension, that do not have the anatomy intact. Perineology, a logical deduction from the observation of the neuro-muscular-conjunctive anatomic unit of the entire pelvic floor and the functional interactivity of individual perineal areas, is more than just the fruit of the union between urogynecology and proctology. A real interdisciplinary process, it combines in a singular concept the study of perineal function disorders. As a united or singular approach, perineology must enable to understand better the balance that existsamong individual perineal structures and ensure the sustained functional balance among all perineal structures while avoiding iatrogenic attitudes.

(32) May pelvic Floor Rehabilitation & Physiotherapy better sexual Dysfunction?

Andre Mamberti-Dias Centre de rehabilitation Perineologique 

Sexual problems are common in men.
They occur for several reasons, many of which are correctable. New diagnostic tests make possible the recognition of specific causes of these dysfunction. Besides medical treatment and psychological procedures, other therapeutic options like pelvic floor rehabilitation & physiotherapy with electrical stimulation & biofeedback, are available. Physiotherapy in a few cases could be advocated to these people because it is a non invasive technique, without any side-effects and
providing good results. The options that have been available in France since 1985 are outlined by the author. Before any re-education for a sexual dysfunction one uses to do a functional assessment. We present now our study carried out between 1990 and 1999 with 190 male patients consulting for impotence and/or premature ejaculation of whom one found perineal dysfunctions
such as reverse command, non voluntary contractile pelvic floor & inefficient bulbo-spongiosus.
The author proposes a complete functional assessment for evaluating patients and gives results on his study with 190 patients.

(33) Role of Computers in Problem Based Learning

A. Karim Qayumi, M.D Ph.D. Professor, Department of Surgery, University of British Columbia 

Computer assisted learning is a hot topic and is evolving parallel with the rapidly growing computer technology. Today, modern computers with sophisticated software are able to create a new dimension in the application of many important pedagogical principles and philosophies. Modern computers with excellent multimedia applications are capable of simulating a realistic situation that enriches the educational environment, improves the learning process and brings new challenges to the process of Òlearning by doingÓ. The use of computers in medical industry and in medical education lag far behind other applications in the industrial world. Although a great deal of computer assisted learning programs have been developed in the last decade and patient simulation has been attempted, there are no computer programs in the market that are capable of simulating the realism of the patient-doctor relationship. The computer software ÒcyberPatient TM** developed by the Department of Surgery, University of British Columbia is able to ralize this long term dream of medical students and educators. The discrepancy between theoretical and practical medical knowledge in the classical medical education was greater than in any other aspect of science. In classical medical education, diseases were taught beginning with etiology and pathogenesis to signs and symptoms. In practice, the patient comes to the doctor with complaints and the doctor has to think back ward to find out about the etiology and pathogenesis. This discrepancy created enormous difficulties for interns and young doctors with respect to the application of theoretical medicine to medical practice. The new curriculum, however, has brought new challenges and problems of its own. Some of the problems include patient availability, increased demands for teachers, and in turn, significant increases in the costs of medical education. Intensive use of computers may be a solution for problem-based learning. The aim of this presentation is to give an overview of computer-based learning and its place in the future of medical education, in the area of Pelvic Floor Disorders. 

(34) Effects of Two Amphibian Tachykinins, PG-SPI and PG-Ml, on Different Models of Experimental Colitis in Rats.

Broccardom, CarpinoF*., Guglietta A., Improta G., Petrozza V.
Dept. of Human Physiology and Pharmacology and *Dept. of Experimental Medicine and Biopatology University of Rome Ò La SapienzaÓ. P. le A. Moto 5, 00185 Rome,Italy. 

Previous reports have shown that tachykinins (TKs) play a rote in the pathogenesis of experimental colitis. The aim of this work was to evaluate the effect of two natural TKs, NK1 (PG-SPI) and NK1 (PG-KII) receptor agonists, on the trinitrobenzene sulfonic acid (TNBS) and destran sodium sulfate (DSS) induced colitis in rats. Colitis was induced by a single intracolonic instillation of 0.5 ml of 50mg/kg TNBS in 50% ethanol or by an oral administration of 5% DSS for seven days. Each group was daily treated intracistemally by PG-SPI and PG-Kll (0.5, 5, 50
mg/kg/day) Ib dat 3m TNBS-treated animals were sacrificed and severity of gut inflammation evaluated by measuring myeloperoxidase (MPO) activity, interleukin- I (IL-i) production and macroscopic and histologic colonic damage score. DSS-treated animals were daily checked for the extent of survival and for stool consistency or fecal blood. In the TNBS group,
PG-SPI and PG-Kll induced an increase of the severity of colonic damage score. PGSPI stimulated the production of IL-l and PG-Kll increased granulocyte infiltration into the colon (MPO activity). In the DSS group, PG-SPI and PG-Kll decreased the percentage of surviving animals, increased the number of rats that developed loose stools and blood in the feces with the greatest differences observed in the first few days after DSS administration. These results support the hypothesis of central NK1 and NK3 tachkinin receptor system involvement in the acute phase of experimental gut inflammation in rats and suggest that the TK receptor antagonists may offer a novel therapeutic approacr for treatment of many inflammatory disorders.

(35) Topographic Anatomy of the Pelvic Floor
with Speical Reference to Thano-Rectal Tract 

Carpino F,1 Petrozza V.1, Carpino G.2, Brunone F.3 and BarberiniF.2 1Dept. of Experimental Medicine and Biopathology, 2Dept. of Human Anatomy, 3School of Anatomical Design, university of RomaÓLa SapienzaÓ 

In order to provide useful information for colorectal
and gynecologic surgery of pelvic organs, topographic anatomy of the pelvic floor is descnbed with special reference to the ano-rectal tract. Levator ani is the largest muscle of the floor. Medial margins of muscles of both sides are anteriorly separated by the passage of urethra, vagina and rectum. Fibers of the medial part of leavator ani, reflecting on the postero-inferior part of prostate or vaginal wall, form puboprostaticus or pubovaginalis muscles, respectively. Other fibers, after encircling posteriorly the ano-rectal junction (puborectal muscle), converge in the rectal musculature and act as an important sphincter. Laterally, pubococcygeal and iliococcygeal fibers form the anococcygeal ligament behind the rectum. Distally, the rectum is surrounded by the external anal sphincter that fuses superiorly with the pubococcygeus muscle and extends inferiorly up to the dermis. Pelvic fascia from the superior surface of the floor folds up on pelvic organs, forming individual sheaths. The floor is reinforeed anteriorly by the urogenital diaphragm, strictly adhering to the inferior surface of leavator ani. The pelvic peritoneum between urinary bladder or uterus and rectum forms the recto-vesical or recto-uterine pouch. The pouch is divided by the uterosacral ligaments in a superior and an inferior part, corresponding to the uterus and the posterior vaginal fornix, respectively. In the embryo the coelomic cavity extends distally, following the growth of the urorectal septum which is the anlage of perineum. This caudal portion of the coclomic cavity, because of progressive coalescence of peritoneal leaflets, will form the peritoneal pouch which extends up to the pelvic floor (fetus), the prostate base (newborn) and the urinary bladder fundus (adult). Consequently, the rectovesical or the rectovaginal septum arises connecting the perineal body to the rectovesical or recto-uterine pouch. Coalescence and depth of the pouch may vary: its bottom is usually5-6cm above the anus but distance may be reduced even to 1-2 cm (in this case, intestinal loops may lie in perineum). The peritoneum covers the rectum up to the junction of its medium and inferior thirds at the level of the second valve of Houston whereas laterally forms the pararectal recesses. Posteriorly, the retrorectal space-containing median and lateral sacral vessels, lymph nodes, anterior branches of sacral nerves and sacral tract of the sympathetic trunk-separates the rectum from sacrum and coccyx. Inferiorly, perirectal spaces are closed by the adhesion of levator ani to the rectal musculature. Superiorly, the serosa forms a mobile layer on the rectum so that perirectal spaces may communicate with those retroperitoneal prevertebral and iliac ones.

(36) Anorectal Manometry in Faecal Incontinence 

La Torre V, Pontone S , Nicolai A e La Torre F III Clinica Chirurgica 

Faecal incontinence is an inability to confine the process of defection to a socialy appropriate place and time. The etiological causes leading to faecal incontinence may be classified as follows: alteration of stool consistency-diarrhoea; reduced rectal reservoir capacity or compliance; reduced rectal sensation; alteration of the sphincter mechanism or of the pelvic floor. The manometric approach to the study of the ano-rectal region is a simple technique provided useful information regarding ano-rectal motor patterns in faecal incontinence. Thanks to this thechnique we have the opportunity to know: Effective Length of sphincter pressure zone (EL); Maximum Pressure (MP) and its Distance from the anal varge (Vds); High Pressure Zone (HPZ) and rectal compliance. The pressure signals are preprocessed to remove technical imperfections, then the anal canal longitudinal pressure profiles are analyzed for maximum and minimum pressure values existing in each anal canal axis and their distance from the anal verge, both at rest and during squeeze and straining. The clinical benefit of knowing these parameters is evident whenever, for example, in anal canal important pressure deficit were limited to same quadrants, as a consequence of trauma or surgery or spinal injury. Such a technique is fundamental for the diagnostic of pelvic floor disorders and takes into account physiological and methodological consideration with computerized data.

(37) Conservative Treatment of Faecal Incontinence 

Pontone S. La Torre V, Nicastro A, Latorre F. Istituto 3 Clinica Chrurgica 

Faecal incontinence is a highly disabling symptom which causes the patients to gradually abandon all forms of social, family and working relationships. The treatment of faecal Incontinence can be distinguished on the basis of two principles: the causes provoking the symptom and the general health conditions of the patient. The techniques to be adopted for self-sufficient patients who enjoy good general health conditions and suffering from faecal incontinence are different. Adopted initially in cases of surgical failure and considered as being only palliative, rehabilitation techniques have evolved from simplistic physiotherapeutic actions to complex techniques compounded by physiokinesitherapy, to teach the patients to recognise the movements of the pelvic floor muscles and to eliminate the agonistic and antagonistic synergies of continence; electrostimulation, applied in order to improve muscle trophism and to learn the motor scheme of sphincter contraction biofeedback, to teach the patients to contract their sphincter and improve the strength and duration of the contraction. In order to evaluate how efficient re-educating the anal sphincter really is in the treatment of faecal incontinence we have undertaken over the last ten years a longitudinal study on the simultaneous use of the three techniques on all patients affected by this symptom that were referred to us. The study involves 116 patients (31M, 85F) mean age 43.9 (range 11-86), with faecal incontinence of varying etiology, assessed by means of a scoring system (modified by Wexner) which envisages three levels of incontinence; mild (<5). Moderate (6<10), severe (>10). Results were evaluated at the end of the first fifteen sessions, after a second booster cycle and after one year. With respect to the general case series the results are to be presented as follows considering the three patient groups taken into account therapeutic success was achieved in 95% of the cases, considering all the patients on the rehabilitation programme 81,5% of the cases were successful.

(38) The Use of Flow Equation in Predicting Outcome After Surgery for Patients with Rectocele and Constipation

Prof. Ahmed Farag M.D. Professor of General Surgery, Faculty of Medicine,
Cairo University

Background: This study was designed in order to determine whether the flow equation can be used in predicting outcome of surgery in patients suffering from rectocele and constipation.
Methods: 10 patients with rectocele and constipation (rectocele group), 10 age matched multiparous females (control group), and 10 age matched multiparous females patients with obstructive constipation without rectocele (constipation group), were studied using history taking anorectal examination, manometry and defaecography. The volume of the rectoceles was measured in the lateral defaecographic views. The anal canal resistance and flow, and the rectocele resistance to flow were measured mathematically using flow and resistance equations.
Results: The flow equation could detect normal defaecation in 90% of cases in the control group (flow index equal or more than 1 c.c. barium sulphate (BaSO4) per second, and could diagnose obstructed defecation in all the patients in constipation group (flow index < 1 c.c BaSO4/s). When used to study the rectocele group. The flow equation could predict successful outcome in the 4 patients who had normal defaecation postoperatively (flow index > 1 c.c BaSO4/s) and in the 6 patients who did not regain normal defaecation after surgery (flow index <1c.c./s).
Conclusion: The flow equation could accurately predict outcome in the studied 10 rectocele patients.A larger double blind controlled study is needed to verify the above mentioned data.

(39) Anal Incontinence and Rectocele, by Perineal Tear III - IV Degree 

Carcia - Donas . A ; Fernandez, P; Sanchez - E ;Galvan , J; Bellido - J; Guerrero, J.M Ortega. J. M; Canti Hana, J. Spain

80 year old patient that consults for incontinence for gases, pluse solid and liquid stools. Minor urinari incontinence. Under exploration presents situation after total perineal tears repaired bygynecologists. We find : 1o - Absence of the perineum. 2o - The anus was implanted in the vagina. 3o-And a Rectocele.By the digital examination: Unstressed anal sphincter. The endoanal sonography presents rupture of the anterior part of both internal and external anal sphincter, as well as a great separation of the sheaves of the elevators ani muscles. After oral intestinal preparation, 48 hours before the intervention and cleaning enemas, the intervention was carried out, in gynecologycal position. Cleaning of the vagina and the rectum with antiseptic solution. Infiltration with Epinephrine Sol. at 1/50000, local to get ischemia and better dissection of the planes, 15 minutes before beginning the procedure. Dissection of the rectovaginal plane. The Douglas sack was rejected. Localization of the elevators muscles fibers, and repair of them., external, and. Repair of the internal sphincter, without over lapping them. With loose point of non absorvible material. Reconstruction of the external sphincter. Cutaneous plasty of the perine, with two torn pieces of the inferior lip of vulva Resection of the redundant vagina. Suture of the anterior anal verge, to restore it in its normal place. The perineal wound skin was not sutured. Patient had bowel passage at the 5 postoperative days. Shi bekam continent after surgery. The postoperative controls through endoanal sonography and manometry, and also the endoscopy view, as long as plastic status of the perineum are shown in the video.

(40) Our Experience in the Treatment of the Symptomatic Rectocele

Garcia-Donas Abril, A; Galvan, J; Sanchez, F; Fernandez. P; Bellido, J; Sanchez Gey, Fuertes, M; Ortega, J; Cant I Ilana. J. 

The rectocele is a hernia located with more frequency between the anterior face of the rectum and the posterior one of vagina. Not all rectocele are symptomatic. Alone the symptomatic rectocele that cause defecatory disorders (outlet obstruction) are tributary to surgical treatment. Patient with incontinence they can also have a rectocele. In this study we will refer to the symptomatic female rectocele. We have found, between 1997-99, 41 women with anterior rectocele, of those only 19 (46,3%) they were symptomatic. Middle age 51 (range 40/62). Among the 19 women they added of childbirths 62 (range 2-6 childbirths). 42 (67,7%) episiotomy ; 8 (12,9%) forceps; 4 (1,2%) perineal lacerations. Associate Disease: 3 (15,8%) hemorrhoids; 3 (15,8%%) total rectal prolapse; 2 (10,5%) anal fissures ; one perineal tear III Grado. Two patients rejected surgery. The 42 patients consulted for constipation that once analyzed the word constipation, in 20 cases turns out to be defecatory disorders. 4 made reference to a bundle in posterior vagina face; 4 manual assistance (digitation); 12 they presented constipation that palliated with laxatives daily; 4 sensation of incomplete defecation; 10 straining at defecation; 4 explosive defecation; 7 blood at defecation; one leakage; single 11 patients took rich residuals diet, and very few they drank more of a liter of water daily. The diagnoses it was made essentially by the history and the digital rectal exploration, being confirmed this by means of a defecography. By all patients who underwent surgery was carried out before and after surgery; defecography, anorectal anometry and to some endorectal sonography. Technique: Transperineal anterior levatorplasty, without folding the anterior rectal wall. Sutures of the subcutaneous. The skin remain opened. This technique was carried out by 18 patients. 
Results: In all patients the outlet obstruction, and the sensation of incomplete deposition disappeared. In three cases, there was a superficial infection of the wound. Transient fecal incontinence in a case. A patient make a low rectovaginal fistula. A relapse of the rectocele, returned after reintervention by the same technique with success. This patient presents
transitory dispareunia. Colonic constipation remain after surgery by one patient.
Conclusion: Rectocele is an alteration of the pelvis floor muscle not very well known by the physician. It is necessary to distinguish between constipation and outlet obstruction. It seems to have little relationship with the constipations of colonic origin or for other causes. The rectocele is essentially a consequence after lacerations of the pelvic floor muscle. In well selected cases surgery has a high grade of success.

(41) Laparoscopic Rectopexy 

Creperio G. Italy 

Background: This study illustrate our experience in treating of rectal protapse. 
Materials & Methods: In case of rectal prolapse we adopted the Repstein - Wells technique by laparoscopic approach. In our experience we treated nine patients. We have no complications intra or postoperative. The average time of discharge is 5 days and the patients benefit of all advantages of laparoscopic technique. The video shows the laparoscopic technique. 
Conclusion: In rectal prolapse laparoscopic surgery is the best treatment because permits a rapid
discharge, less post operative pain and the results are the same than open surgery.

(42) Our Experience of Total Rectal Prolapse

Accarpio G., Barbanera M., Squillarlo E., Accarpio E.T., Ravera G.*

Summary: The Authors have surveyed the results of 52 cases of rectal total prolapse treated in the last ten years. They have been able to ascertain that thebest results has been obtained through an anterior resection, both for the low percentage of recurrences and for the remarkable low percentage (p<0.05) of constipation, associated to the fixation of the rectum to the promontorium with stiches or with a prothesis. Incontinence, which is always present for at least six months after the operation, has decreased in almost all the patients. 
Introduction: Total rectal prolapse represents to the patient, especially when elderly, a very upsetting menomation. It is important to point out the symptoms most commonly associated with this condition, especially when the disease is advanced: 1) rectal dislocation 2) persistent upsetting of the intestinal functions; 3) bothersome incontinence. In the early stages of the prolapse diagnosis is not simple and requires accurate tests, such as defecografy, manometry, etc. An abnormal motility of the pelvic floor is the Optimum movenso which sets off a rectal invagination and an anal protrusion, in the manner of a finger glove turned inside-out, thus stretching the pudendal
nerves and bringing the patient to a complete incontinence. In the treatment of total prolapse different techniques have been proposed, which indicate the difficulty at finding a definite solution to the problem. Our experience is based on patients whose age ranges between 20 and 90 years and we believe that when feasible, transabdominal sigmoid resection is the treatment of choice, especially when the sigmoid colon is long. Surgeons major concerns are undoubtely the risk of
relapse, persistent constipation and most of all, perioperative complications, such as anastomotic
dehiscence. 
Patients and Methods: Fiftytwo patients affected by a total prolapse have been treated in a ten-year period. Eight of them were very ill and, therefore, underwent a perineal treatment under local anesthesia. As for the remaining patients (44), 24 were operated through the abdomen with the insertion of a prothesis (Ripstein), whereas 20 patients underwent a sigmoid resection (Frykman Goldberg) (1, 2). All the patients who underwent resection had the anastomosis tested hydropneumatically (Fig. 1). The youngest patient, a 20-year-old female, said she had been affected by a rectal total prolapse since she was a child. At time, the rectal protrusion reached
20cm which, obviously, represented a big hindrance to her life. Another female patient, who was 34 years old, had a sigmoid colon whose length was over one metre, and the histological exam showed hypertrophy of Meiseneris and Hauerbachfs Plexum (Fig. 2). 
Results: There have been neither deaths nor anastomotic leaks. After 8 years there were two cases
(10%) of recurrences in patients treated with resection, and four cases (about 17%) treated without
resection. Such percentages compared through Fischeris Exact Test do not appear statistically different. Constipation has been present in 40% of the cases treated without resection whereas in only 8% in the cases with resection. Such percentages, tested according to Fisheris Exact Test, appear statistically different (p< 0.05), which suggests that patients who underwent resection had better result. Incontinence was improved in 85% of the cases. Fifty percent of the patients who still presented incontinence underwent under local anesthesia a sphincteroplasty according to Parks, after about a year from the rectal prolapse operation. 
Discussion: The major postoperative complaint of these patients has been about having problems in
evacuating especially the ones who did not have resection and also two who had it. These patients
usually complain both before and after operation of being unable to defecate, as recently described by Shafik in Disease Colon Rectum (December issue) who defined such complaint as rectal arrhythmia. Several surgical techniques have been performed in order to find a solution to the problem, which prove how difficult this pathology is. Surveys carried out by Hughes (1949) (6) and Porter (1962) (10) have shown satisfactory results Also Roscofs and Grahamis technique, promoted by Golligher (1958) (3, 12), with an anterior resection (Muir, 1955) (4), the one performed with a polyvinyl alcohol sponge implant (Wells, 1959) (5), and the one performed with a goretex or mesh prothesis (Ripstein) (11) have proved satisfying. The technique promoted by Frykman and Goldberg (1969) (2), firstly performed without resection and successively with an anterior resection, has been associated with excellent postoperative results (8). Several studies, including our experience (1990) (1), have shown how effective such technique is, especially when performed with an anterior resection, and how convenient and simple is as to its accomplishment. The anastomosis may be performed either manually, or by stapler, or by a bioassorbable ring through the anus or the abdomen. In all cases, it is important to secure the rectum to the promontorium with
non-absorbable stitches (3.0), a number of four for each side. As an alternative, a mesh or goretex may be used to secure the rectum.

(43) Deep Pudendal Reflex : A New Pudendal Anal Reflex

Contreras Ortiz, O. ; Bertotti, A.C.; Coya Nunez, F. 

Aim of the study: To analyse deep pudendal reflex responses after transrectal and transvaginal pudendal nerve stimulation at ischial spine. 
Methods: 32 healthy women ranging from 20 to 68 years old (51.5 + 10.36) were tested for Deep Pudendal Reflex (DPR). After transrectal examination 8 healthy women ranging from 25 to 65 years old (50.23 + 11.63 ) were tested for DPR after transvaginal pudendal nerve stimulation. Recordings and nerve stimulation were done using St. MarkÕs electrodes (DANTEC 13<40). Electrical stimuli were given at sciatic spine applying square stimulus of 0.2 ms duration and 0.5Hz frequency. The conduction time was measured as the
latency from the time of stimulation of the starting point of the reflex response curve. The shortest
latency of various responses was accepted and measured in ms. The amplitudes were measured in m. 
Results: We obtained reproductible DPR in all subjects. Transrectal DPR mean latency was 36.18ms, SD:4.29 ms; mean amplitude was 337.50 m+218.49 transvaginal DPR mean latency was 35.97 ms, SD 4.69 ms, mean amplitude was 359.67m + 245.02. There were no significant differences between both responses. 
Conclusion: DPR is a pudendal anal reflex that may be obtained after transvaginal or transrectal pudendal nerve stimulation. There are no differences between both responses, although the first one is better tolerated by women.

(44) Posterior Rectocele : A Study and Evaluation

Yehia Ahmed Ali (1) and Ali A. Shafik (2) (1) Professor, Department of Radiology, Faculty of Medicine, Cairo University, Cairo , Egypt (2) Lecturer, Department of Surgery, Faculty of Medicine, Cairo University, Cairo , Egypt. 

Objective: This work was undertaken to study and evaluate the posterior rectocele.
Study Design: A total of 70 patient were submitted to defecography due to chronic constipation.
Results: Nine patients were found to have posterior rectocele. In all patients levator ani dysfunction was present. Five patients had combined anterior and posterior rectocele and all were females. Four
patients had only posterior rectocele and all were males.
Conclusion: Posterior rectocele is uncommon rectal wall disorder. levater ani dysfunction plays a major role in posterior rectocele existence.

(45) Cauterization - Plication Operation in the Treatment of Complete Rectal Prolapse

Olfat El-Sibai*, MD, PhD and Ali A. Shafik**, MD* Chairman, Coloproctology Unit and Gen Surgery Department, Faculty of Medicine, Menoufia University** Dept. of Surgery, Faculty of Medicine, Cairo University Egypt 

The current communication presents a simplified technique for the treatment of complete rectal prolapse (CRP). The study included 28 CRP patients (17 females, 11 males) with a mean age of 36.4 years (4 were children; 3-12 years old). 14 of the patients had
fecal incontinence. With the patient under general or spinal anesthesia and in the lithotomy position, the prolapsed rectum was pulled outside the anal orifice and the mucosa was cauterized in vertical lines thus exposing the muscle layer which was plicated by 2/0 Dexon sutures. Posterior levatorplasty was done in 14 adult patients in whom the length of the prolapsed
segment measured more than 4 inches and who were incontinent. The postoperative follow up was 31.6 months. Five patients had mucosal prolapse and one had recurrence 2-3 months after operation. Mucosal plication was performed for the 5 patients and repetition of the operation for the recurrent patient. Fecal impaction, anal stricture and fistulae were not encountered. The technique is simple, easy and with minimal complications.

(46) Treatment of Anorectal Fistulae by Combined Laying-Open Surgery and Electrocauterization 

Olfat El-Sibai* MD, PhD and Ali A. Shafik** MD *Coloproctology Unit, General Surgery Department, Faculty of medicine, Menoufia University ** Department of Surgery, Faculty of Medicine, Cairo University, Egypt

Anorectal fistula is confronted with two complications: (1) sphincter dysfunction and (2) recurrence. This work investigated the effect of electrocauterization in the treatment of fistulae. The study included 42 patients with transphincteric anorectal fistulae, of which 36 were posterior,
branched and recurrent. The mean age was 33.7 years; 28 were males and 14 females. The procedure was performed under local or spinal anesthesia with the patient in lithotomy position. A probe was introduced in the fistula track after injection of 0.4 ml methelin blue into the external opening. The track was layed open until the level of the anorectal ring and to the side tracks. The deep part of the fistulous track was probed and electric current was switched on to cauterize the track. This was done instead of applying seton to the deep part of the track and cutting it in a second stage of operation. The mean hospital stay was 18 days. Antibiotics and mild analgesics were given to all patients. This technique was able to treat 36 patients (70%) successfully. No continence disorders occurred but recurrence was reported in 6 patients (14.3%) who were re-treated by electrocauterization of the fistula in the outpatient clinic. In conclusion, electrocauterization of the part of the fistula track above the anorectal ring is a simple and easy technique with safe results.

(47) Sacral Nerve Modulation for Chronic Constipation

E. Ganio*, A. Masinx, C. Rattol, M. asile2, G Clerico*, A. Realis Luc*, G. Lisex, GB Dogliettol, S. Gidaro2 on behalf of GINS group* Colorectal Eporediensis Centra, Ivrea, xUniversita di Padova, Clinica Chirurgica II, 1 Policlinico A., Gemelli, I Clinica Chirurgica, Roma, 2Ospedale di Pescara.

The management of chronic outlet constipation is sometimes complex. Many patients lack a coordinate activity of the rectum and the anal sphincters which is not amenable to simple surgical treatments. Sacral neuromodulation (SNM) has been experimentally used in these patients to improve defectory dysfunction. 
Patients and Methods: Data are obtained from the national prospective register. Nine patients with chronic idiopathic constipation (2 males, 7 females mean age 53.4 years, range 31- 72) who underwent definitive implant of sacral neuromodulation after the PNE test were included in the study. Constipation was idiopathic (7), secondary to mielitys (1) and to herniated disc (1). All the patients complained of outlet constipation with normal or left-colon prolonged transit time and without any demonstrable anatomical alteration. The patients were selected amongst 25 patients previously submitted to peripheral nerve evaluation test (PNE). PNE was performed after medical treatments had failed. 
Results: The mean duration of the tests was 16 days (range 7-28). During PNE we observed a decrease in the WexnerÕs score from 12 (range 8-15) before the test to 2.4 (range 0-6) during the test (p<0.01). Inimplanted patients the Wexner score and from 12.5 (range 9-16) to 3.4 after 3 months (range 0-6) (p<0.01) and to 2.9 at the last follow-up (4.9 months (range 3-12)
(p<0.01). The most important manometric findings were an increase in maximal resting pressure (MRP baseline 67+ 25 mmHg vs 69 +14 at the end of PNE and 78+ 10 at 3 months follow-up) and maximal squeeze pressure (MSP 120?33 mmHg baseline vs 140?52 at the end of PNE and 132+62 at 3 months follow-up and a reduction in the rectal volume for the feel (pre-stimulation 99+47 ml, to 81+37 ml at last follow-up) and urge to defecate threshold (pre-stimulation 199 +80 ml, to 140 + 40 mlat last follow-up). All the implanted patients showed an improvement in symptoms.
Conclusion: The findings of this preliminary study show that SNM is a promising option for intractable chronic constipation, particularly in cases of outlet obstruction.

(48) Selection Criteria for Sacral Nerve Stimulation in Patients with Fecal Incontinence

E.Ganio, M.D., A. Realis Luc, M.D., G. Clerico, M.D., M. Trompetto M.D. Colorectal Epordienisis Centre - ASL 9, Ivrea, Italy 

Sacral nerve stimulation (SNS) appears to offer a valid treatment option for some patients with fecal incontinence and functional defects of the anal sphincter. However we lack of a definition for the candidates for SNS. 
Patients and Methods: To identify SNS selection criteria 32 patients, 5 males and 27 females 27, mean age 55.3 years (range 28-74), with fecal incontinence for solid or liquid stool at least once a week during the previous two months have been evaluated with peripheral nerve evaluation (PNE). Seven patients have failed standard surgery (1 rectopexy, 4 pelvic floor repairs, 2 sphincteroplasties) and an elapsed time of at least 6 months was considered before the PNE. Associated diseases were scleroderma (1 pt) autonomic nerves lesion (2 pts), spinal injuries (7 pts), and mielitys (3 pts). Twenty-eight patients (87.5%) completed a minimum stimulation period of 7 days (median 10.7 days (range 7-30). Twenty-one patients (65.6%) had urge incontinence (fecal loss at the first urge to defecate) and 7 (21,8%) had passive incontinence (inadvertent and unpredictable fecal loss). Three groups of patients were identified according to the etiology of incontinence; complete peripheral nervous lesion (CPML) secondary to spinal cord trauma or surgery for protrusion (3 pts) partial peripheral nervous lesion (PPNL) secondary to surgery or trauma of the spinal cord or medullar disease (8pts), idiopathic incontinence (IFI) with diffused weakness of the pelvic floor and the anal sphincter (17. pts) All the patients underwent preliminary investigations with anorectal manometry, PNTML, anal ultrasound, defaecography. To evaluate the functional results of PNE patients completed a clinical diary of fecal incontinence and bowle movements episodes in the two weeks proceeding, during and in the two weeks following the PNE . PNE was considered positive if complete cessation or reduction by more than 50% in leakage episodes for liquid or solid stool (LSE) during the test period and a rapid return to pre-PNE conditions when stimulation was turned off. 
Results: Sixteen out of the 28 valuable patients (57%) had a reduction in leakage episodes for liquid or solid stool by more than 50% and five (18%) by more than 80%. Urge incontinence patients showed a better improvement; prestimulation median 5,1 LSE per week
(range 1-14) post stimulation median 1.4 LSE per week (0-12); p=0.001. Improvement in passive incontinence was from a prestimulation median of 5.3 LSE per week (0-14) to a post stimulation median of 2.9 LSE per week (0-14); p = 0.51. Patients with CPNL failed the PNE. Five
patients (51%) with IPNL improved more than 50% and one (12.5%) by more than 80%; 11 patients (84.6%) with IFI improved more than 50% and 4 (23.5%) by more than
80%. The most important manometric findings were a reduced rectal distension threshold for rectal filling (failed 5.5 cm H20 (95% CI 15.6-35.3) positive 20.8 (95% CI 16.4 - 25.2), P=0.01) and for urge to defecate (failed 48.8 cm H20 (95% CI 29.3 - 57.9) positive 37.8 (95% CI 32.2 - 43.3), P = 0.002) in patients with clinical positive outcome. PNTML did not correlate with the results of the PNE (failed PNTML 2.8 msec (95% CI 2.1 - 2.9), positive 2.5 msec (95% CI 2.3-2.7), P=0.6).
However patients with complete lesions of the pudenda did not respond to the PNE.
Conclusions: Results of our investigation showed that patients with PPNL or IFI and urge incontinence can be
helped by SNS. A conserved rectal sensation is also important in selecting the patients for PNE evaluation.

(49) Sacral Nerve Modulation for Fecal Incontinence 

E. Ganio*, A. Masinx, C. Rattol,D. ltomare2, G. Pellicioni3, R. Ghiselli3, W. Ripettid4, G Clerico*, A. Realis Luc*, G. Dodix, GB Dogliettol, V. Memeo2, O. Scarpino3, Saba 3, A. Arullani4, on behalf of GINS group 
* Colorectal Eporediensis Centre, Ivrea, xUniversit? di Padova, Clinica Chirugica II, 1Policlinico A.Gemelli, I Clinica Chirugica, Roma, 2Policlinico di Bari, Ancona, 3INRCA, Ancona, 4 Campus B. Roma. 

Purpose : Sacral neuromodulation has been used in the treatment of fecal incontinence. Aim of study is presenting the results of national register as of November 2000.
Patients and Methods: Data obtained by the Italian Collaborative Study Group were organized in a
prospective register. The Study included 18 patients with fecal incontinence (2 males, 16 females; mean age 58.6 years, range 29-77) who underwent the permanent implant of sacral neuromodulation after positive response to temporary test (PNE). They had intact or
repaired (1) sphincters without signs of severe denervation at EMG. Etiology was idiopathic (11 pts) or following to pelvic surgery (2), spinal surgery (2), rectopexy (1), scleroderma (1). The results of the PNE tests were evaluated with a defecatory diary completed by patients during the test and with an anorectal manometry before and on the last PNE day. The mean duration of the tests was 13 days (range 7-20). Results : Among the 52 patients who underwent short-term stimulation, 18 were selected for permanent implant. During PNE we observed a decrease in the number of incontinence episodes for liquid or solid stool in 7 days from 5.5 (range 2-14) before to 1.5 (range 1-9) during the test (<0.01) After sacral permanent stimulation the incontinent episodes decreased from 6.5 (range 8 - 10 to 0.8 after 3 months (range 0-3) (p<0.01) and to 1.1 (range 0-3) at the last follow-up (12.4 months, range 1-39) (p<0.01) in the 18 implanted patients. All the patients showed
an improvement in symptoms. At anorectal manometry, we found an improvement in the mean maximal resting pressure (MRP 35.3+ 11.6 mmHg at baseline vs 39.3+ 7.9 at 3 months follow-up and during squeeze (MSP 58.3 + 25.3 mmHg at baseline vs 78+ 21.9 at 3 months follow up
Conclusion: Sacral neuromodulation can be considered an option for fecal Incontinence treatment.

(50) Radiological Rectal Configuration In Idiopathic Constipation Disorder

Moustafa Gad, Ahmed Shafek, Ali A. Shafik and Dr. Ashraf 

Still there are controversies with respect to the rectal configuration and number of its transverse folds (T.F.) in subjects with defecation disorder. The purpose of this study was to identify the rectal configuration and its T.F. in idiopathic constipation. Double contrast barium enema examination of the rectum and sigmoid was performed to fifty patients with idiopathic constipation were selected after excluding the cases with organic lesion producing constipation like tumor, strictures, diverticulitis or others. The mean age of the patients was 54.06 years (range 40-73). Thirty eight males and twelve females. Another control group of ten normal volunteers with no gastrointestinal complaints were also included within this study. The mean age of the control group was 55.4 years, seven males and three females. The rectal configurations and the number of the rectal T.F. in 50 studied patients varied. The subjects were divided according to the number of rectal T.F. into four different groups. It seems that the rectal configuration changes and passes into four stages in idiopathic constipation before reaching to the late valveless stage with straight rectal curve and obtuse recto-sigmoid angle with or without rectocele.

(51) The House Flap in Anal Defects: An Easy but Effective Solution. 

Lia pisegna Cerone, Franco Galanti, Roberto Bellomo, Aldo Infantio Padova University 

Introduction: Cutaneous advancement house flap is a random flap consisting of cutaneous and subcutaneous tissue. in anal keyhole deformity its versatility and easy execution represent advantages over other techniques. 
Methods: From 1998 to 1999 four patients (not suffering from IBD) complaining or faecal soiling by anal minor defect were operated by house flap in spinal anaesthesia and prone jack-knife position. Donator site is sutured using V-Y technique. One patient was affected by a 3 x 3 cm chronic ulcer above the dentate line associated wth a complex perianal fistula, in this case we used a modified technique 3 patients had keyhole postsurgical deformity. 
Results: Time of healing ranged between 14-20 days No flaps were lost due to ischemia . One atient had a minor wound dehiseence which healed conservatively. No pain, no bleeding, no recurrences of fistula or ulcer were recorded after at least a year follow-up. Discussion : This procedure, easy to perform appears effective to cure minor faecal incontitence. If necessary, the flap standard size (7x5 cm) may be increased and a new mobilization technique can be performed to reach a higher advancement . Soiling and mucous discharge in keyhole anal deformity can be cured by this advancement flap.

(52) Understanding the function through the image : ultrasound in Perineology

Jacques Beco M.D.Liege University (CHU Sart-Tilman)
Groupement Européen de Périnéologie
Belgium

Introduction

Perineology (http://www.perineology.com) is a new interdisciplinary speciality dealing with the functional troubles of the 3 axis of the perineum and respecting anatomy and biomechanics. One of the best tools of the Perineologist, this “architect” of the perineum, is probably ultrasound. By using different approaches (endovaginal, endorectal, introital, retro-anal) or probes, it is possible to study the urethra, the bladder, the vaginal walls, the ano-rectum at rest, during squeezing or abdominal hyperpressure. Almost all the muscles in this area (urethral sphincters, detrusor, anal sphincters, pubo-rectal, levator plate, bulbo-cavernosus) are under the scope of ultrasound.

How is it possible to study the 3 axis of the perineum? 

Gross anatomy (sagittal section)

By using a classical sector probe in the introïtal position, with a large field (180°), it is possible to study bladder neck descent, cystocele, rectocele, enterocele, opening of the hiatus and perineal descent during abdominal hyperpressure. The effect of the pubo-rectal contraction is easily visible during squeezing.

Pubo-rectal muscle

The contractions and relaxations of the two branches of the pubo-rectal muscle are studied using the same probe in para-sagittal section planes.

The urethro-vesical area 

To study the details of the anterior axis of the perineum (bulbo-cavernosus muscles, urethra, bladder, arcuate ligament, Retzius space) the best tool is an endovaginal linear array. The sector probe is used for transverse section and to study the vascular plexus of the urethra using colour Doppler. 

The ano-rectum

The best ways to study the anal sphincters are endorectal linear array for sagittal sections and endovaginal sector probe to obtain transverse sections (if necessary, 360° endorectal probe). 

The levator plate

The levator plate, and its effect on the rectal neck during pushing, is easily visible in the lateral sections using the endorectal linear array. To witness the levator plate and the coccyx in the sagittal plane, you can use the sector probe in the area between the coccyx and the anus. 

(52)Perineology: a new name, a new concept, a new speciality…

Jacques Beco M.D. Liège University (CHU Sart-Tilman)
Groupement Européen de Périnéologie
Belgium

1. Perineology is the result of the merging between urogynecology and coloproctology. This "three-axis approach" is now becoming widely accepted.

2. Perineology deals with the perineum functional troubles (including pains). Non functional diseases (cancer, stones, polyps,...) at any of the three levels must be treated as usual by urologist, gynecologist or coloproctologist. 

3. The aim of Perineology is to restorate "ad integrum" the anatomy in the respect of biomechanics and physiology. Ideally, each defect must be corrected without inducing troubles on the other levels (primum non nocere). The benefit - risk ratio has to be evaluated for each of the procedures. 

4. This approach has to be interdisciplinary and not multidisciplinary. There is only one boss who is the "architect of the perineum", somebody who knows a lot about the anatomy and the physiology of the three axis. This new specialist is called "perineologist". This person could be the surgeon or somebody who tells the surgeon what to do. The perineologist should have an holistic view (integration of the psychology, the way of life, the abdominal wall muscles... in the approach).

5. The functional state of the perineum can be summarized as a T.A.P.E. (Three Axis Perineal Evaluation diagram):
- gynecological axis = sexual troubles - prolaps
- urological axis = urinary incontinence-dysuria 
- coloproctological axis = constipation - fecal incontinence. 

If the T.A.P.E has an hexagonal shape, the result of the surgery is very good. Using this tool enables a monitoring of perineum damages through time after surgery or reeducation. 

More information about Perineology: http://www.perineology.com