23/03/2011
Piercarlo Meinero MD
What are the critical points
of the proctological examination today?
 We can only detect the morphological aspects of the anus and
the rectum but not their functionality.
 At present, a device does not exist that, already at the first
visit, allows us to supect the presence of attendant diseases and
also to predict postoperatory complications.
23/03/2011
Piercarlo Meinero MD
Minor pathologies
Critical point
Negative anamnesis
Routine exams
Positive anamnesis
Other exams
Surgical treatment
23/03/2011
Piercarlo Meinero MD
Proctological Minor Diseases
Negative anamnesis
Other tests
Rectal sensitivity data
23/03/2011
Piercarlo Meinero MD
The MFA doesn’t replace manometry!
It places itself between nothing and manometry.





23/03/2011
Rectal Sensation Test (RST)
Balloon Expulsion Test (BET)
Extent of Prolapse Assessment (EPA)
Anal Canal Length Measurement (LMAC)
Proctoscopy
Piercarlo Meinero MD
Rectal Sensitivity
Rectal sensation is commonly tested by manometry
(balloon distention), detecting the rectal sensitivity
thresholds.
Guidelines do not exist that provide for the anorectal
manometry in patients with minor diseases (ex.
mucosal rectal prolaps and/or haemorrhoids).
23/03/2011
Piercarlo Meinero MD
Rectal Sensitivity Thresholds
FS = First Sensation
(n.v. 30-60 cc of air)
DDV = Defecatory Desire Volume
(n.v. 60-160 cc of air)
MTV = Maximum Tolerable Volume
(n.v.. 160-270 cc of air)
23/03/2011
Piercarlo Meinero MD
Rectal Sensitivity Test (RST)
23/03/2011
1
2
3
4
Piercarlo Meinero MD
Threshold Alterations
RECTAL HYPERSENSITIVITY
(FS<30; DDV<60; MTV<160)
External sphincter disfunctions, faecal incontinence, IBD, MII,
pudendal neuropathy.
Christopher L.H. Chan, F.R.C.S., S. Mark Scott, Ph.D., Norman S. Williams, F.R.C.S., Peter J. Lunnis, F.R.C.S. “Rectal Hypersensitivity
Worsens Stool Frequency, Urgency and Lifestyle in Patients With Urge Fecal Incontinence”. D.C.R. 2005 Vol. 48, N°1: 134-140.
RECTAL HYPOSENSITIVITY
(FS>60; DDV>160; MTV>270)
Constipation, ODS, puborectalis syndrome, solitary
megarectum, dissynergy, idiopatic faecal incontinence.
ulcer,
Marc A. Gladman, M.R.C.O.G., M.R.C.S. (Eng), S. Mark Scott, Ph.D., Christopher L.H. Chan, F.R.C.S., Norman S. Williams, M.S.,
F.R.C.S., Peter J. Lunniss, M.S., F.R.C.S.: “Rectal Hyposensitivity. Prevalence and Clinical Impact in Patients With Intractable
Constipation and Fecal Incontinence”. D.C.R. 2003 Vol.46, N°2: 238-246.
23/03/2011
Piercarlo Meinero MD
Threshold Alterations: the Literature
Emanuel Chrysos, M.D., Ph.D., Elias Athanasakis, M.D., John Tsiaoussis, M.D., Ph.D., Odysseas Zoras, M.D., Ph.D., Antonios Nickolopoulos,
M.D., Joho Sophocles Vassilakis, M.D., Ph.D., Evaghelos Xynos, M.D., Ph.D., F.A.C.S.: “Rectoanal Motility in Crohn’s Disease Patients”.
D.C.R. 2001 Vol.44, N° 10: 1509-1513.
Tetsuo Yamana, M.D., Masatoshi Oya, M.D., Junji Komatsu, M.D., Yasuo Takase, M.D., Noboru Mikuni, M.D., Hiroshi Ishikawa, M.D.:
“Preoperative Anal Sphincter High Pressure Zone, Maximum Tolerable Volume and Anal Mucosal Electrosensitivity Predict Early
Postoperative Defecatory Function After Low Anterior Resection for Rectal Cancer”. D.C.R. 1999 Vol.42 N° 9: 1145-1151.
Gloria Lacima, M.D., Miguel Pera, M.D., Josep Valls-Solé, M.D., Xavier Gonzales-Argenté, M.D., Montserrat Puig-Clota, M.D.:
“Electrophysiologic Studies and Clinical Findings in Females With Combined Fecal and Urinary Incontinence: A prospective Study”. D.C.R.
2006 Vol. 49 N° 3: 353-359.
Paul Broens, M.D., Dirk Vanbeckevoort, M.D., Erwin Bellon, M.Sc., freddy Penninckx, M.D., Ph.D.: “Combined Radiologic and Manometric
Study of Rectal Filling Sensation”. D.C.R. 2002 Vol. 45 N° 8: 1016-1022.
M.D. Crowell, Ph.D., B.E.Lacy, M.D., Ph.D., V.A. Schettler, B.S.N., T.N. Dineen, M.D., K.W.Olden, M.D., N.J. Talley, M.D., Ph.D.: “Subtypes of
Anal Incontinence Associated With Bowel Dysfunction: Clinical, Physiologic, and Psychosocial Characterization”. D.C.R. 2004 Vol. 47 N° 10
: 1627-1635.
Marc A. Gladman, M.R.C.O.G., M.R.C.S. (Eng), S. Mark Scott, Ph.D., Christopher L.H. Chan, F.R.C.S., Norman S. Williams, M.S., F.R.C.S.,
Peter J. Lunniss, M.S., F.R.C.S.: “Rectal Hyposensitivity. Prevalence and Clinical Impact in Patients With Intractable Constipation and Fecal
Incontinence” D.C.R. 2003 Vol.46, N° 2:238-246.
Christopher L.H. Chan, F.R.C.S., S. Mark Scott, Ph.D., Norman S. Williams, F.R.C.S., Peter J. Lunnis, F.R.C.S. “Rectal Hypersensitivity Worsens
Stool Frequency, Urgency and Lifestyle in Patients With Urge Fecal Incontinence”. D.C.R. 2005 Vol. 48, N°1: 134-140.
23/03/2011
Piercarlo Meinero MD
Threshold Alterations
External sphincter disfuncions
Hypersensitivity
IBD, Faecal incontinence (FI e UFI)
Pudendal neuropathy
First visit
Normal
ODS Id.Faecal Incontinence (IFI)
Hyposensitivity
Puborectalis Syndrome, Dissynergy
Solitary Ulcer- Megarectum.
To suspect attendant diseases
Other diagnostic tests
Christopher L.H. Chan, F.R.C.S., S. Mark Scott, Ph.D., Norman S. Williams, F.R.C.S., Peter J. Lunnis, F.R.C.S. “Rectal Hypersensitivity Worsens
Stool Frequency, Urgency and Lifestyle in Patients With Urge Fecal Incontinence”. D.C.R. 2005 Vol. 48, N°1: 134-140.
Marc A. Gladman, M.R.C.O.G., M.R.C.S. (Eng), S. Mark Scott, Ph.D., Christopher L.H. Chan, F.R.C.S., Norman S. Williams, M.S., F.R.C.S.,
Peter J. Lunniss, M.S., F.R.C.S.: “Rectal Hyposensitivity. Prevalence and Clinical Impact in Patients With Intractable Constipation and Fecal
Incontinence” D.C.R. 2003 Vol.46, N° 2:238-246.
23/03/2011
Piercarlo Meinero MD
Threshold Alterations
“…despite these observations, the presence of rectal hyposensitivity
is not often considered when clinical decisions are made regarding
the management of patients with functional bowel disorders, and
perhaps more importantly, in the selection of patients for surgery”.
“…the findings of several anecdotal reports suggest that Rectal
Hyposensitivity may be a predictor of poor outcome in patients
undergoing colectomy for slow-transit constipation and patients
undergoing sphincter reconstruction for faecal incontinence”.
(Marc A. Gladman)‫‏‬
Marc A. Gladman, M.R.C.O.G., M.R.C.S. (Eng), S. Mark Scott, Ph.D., Christopher L.H. Chan, F.R.C.S., Norman S. Williams, M.S., F.R.C.S.,
Peter J. Lunniss, M.S., F.R.C.S.: “Rectal Hyposensitivity. Prevalence and Clinical Impact in Patients With Intractable Constipation and Fecal
Incontinence” D.C.R. 2003 Vol.46, N° 2:238-246.
23/03/2011
Piercarlo Meinero MD
Balloon Expulsion Test (BET)
60 cc of air;
The patient is seated;
Maximum time of expulsion 60 sec.
+ Hyposensitivity with ODS and/or anismus
It confirms the diagnosis of ODS
W.R.Schouten, M.D., J.W.Briel, M.D., J.J.A.Auwerda, M.D., J.H.van Dam, M.D., M.J.Gosselink, M.D., A.Z.Ginai, M.D.,
W.C.J.Hop, M.Sc.: “Anismus: Fact or Fiction?”. D.C.R. 1997 Vol. 40 N° 9: 1033-1041
1 James W. Fleshman, M.D., ZeevDreznik, M.D., Edward Cohen, M.D., Robert D.Fry, M.D., Ira J. Kodner, M.D.:
“Balloon Expulsion Test Facilitates Diagnosis of Pelvic Floor Outlet Obstruction Due to NonrelaxingPuborectalis
Muscle”. D.C.R. 1992 Vol. 35 N° 11: 1019-1025.
23/03/2011
Piercarlo Meinero MD
Extent of Prolaps Assessment (EPA)
Without anoscope
150-160 cc of air
Traction-Straining
Vaginal examination
Perineal information
23/03/2011
Piercarlo Meinero MD
Lenght Measurement Anal Canal
(LMAC)
It is possible thanks to the
graduate scale in centimeters;
Useful in case of operation for
faecal incontinence;
It can predict the biofeedback
failure in the cases of anismus.
Poong-Lyul Rhee, M.D., Moon Seok Choi, M.D., Young Ho Kim, M.D., Hee Jung Son, M.D., Jae Jun Kim, M.D., Kwang Cheol Koh, M.D.,
Seung Woon Paik, M.D., Jong Chul Rhee, M.D., Kyoo Wan Choi, M.D.: “An Increased Rectal Maximum Tolerable Volume and Long Anal
Canal Are Associated with Poor Short-Term Response to Biofeedback Therapy for patients with Anismus with Decreased Bowel
Frequency and Normal Colonic Transit Time”. D.C.R. 2000 Vol. 43 N° 10: 1405-1411.
23/03/2011
Piercarlo Meinero MD
Our Own Study (Jan. 2006 – Sept. 2008)
189 patients: 128 PMRE; 61 ODS
To demonstrate that:
The rectal sensitivity thresholds are the same with MFA
and ano-rectal manometry.
The RST altered values, detected with the MFA during
the first visit, could be an expression of attendant
diseases and they could predict post-operative
complications.
23/03/2011
Piercarlo Meinero MD
Statistical Validation
R=0.99, p<0.001
R=0.96, p<0.001
FS
First aim. The correlation on the three parameters related
to the measures detected with MFA and manometry, is
very high (R = Pearson’s correlation coefficient). By
Biostatistic Unit of the Genova University Doctor Mariapia
Sormani.
R=0.98, p<0.001
MTV
23/03/2011
DDV
Rectal sensitivity thresholds are the same if
detected with MFA or ano-rectal manometry
(R = 0,99 p<0,001).
Piercarlo Meinero MD
Rectal Sensitivity Test (RST)
TSR
23/03/2011
30 Hyper
47 Hypo
Other
diagnostic tests
Piercarlo Meinero MD
Diagnostic Assessment
US
EMG,
PNTHL,
Defecography,
Colonoscopy,
Anorectal manometry
30 Hypersensitivity
7 External sphincter disfunctions (23,3%)
10 MII (33,3%)
1 RCU (3,3%)
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47 Hyposensitivity
9 IRA+RA+SlowTr.Constipation (19,1%)
1 Slow Transit Constipation
(2,1%)
17 IRA+RA
(36,1%)
8 puborectalis syndrome
(17,%)
1 Faecal incontinence
(2,1%)
1 Constipation and incontinence (2,1%)
Piercarlo Meinero MD
“Can we forseen postoperative complication?”
URGENCY
Temporary
That resolves itself within three weeks
without consequences;
Permanent
That continues up to three months but
resolves itself without consequences
Severe
That lasts more than three months
and shows itself in an increase of the
daily evacuation but the urgency
decreases or disappears completely.
23/03/2011
Piercarlo Meinero MD
Patient Selection
123 PME
43 ODS
LONGO PROLASSECTOMY
WITH PPH03
S.T.A.R.R. WITH
DOUBLE PPH01
Normal 81
Normal 22
HYPER 27
HYPER 3
HYPO 15
HYPO 18
23/03/2011
Piercarlo Meinero MD
Urgency Incidence
URGENCY INCIDENCE IN 123 PATIENTS OPERATED BY PROLASSECTOMY
RST preop.
P
UDT
UDP
UDS
UD%
UDT/123
UDP/123
UDS/123
UD/123
Normal
81
8
(9.8%)
2
(2.4%)
_
12.2%
15.4 %
8.1 %
4.9 %
28.4 %
HYPER
27
12
(47.5%)
8
(29.6%)
6
(22.2%)
97.1 %
_
_
_
HYPO
15
_
URGENCY INCIDENCE IN 43 PATIENTS OPERATED BY S.T.A.R.R.
RST preop.
P
UDT
UDP
UDS
UD%
UDT/43
UDP/43
UDS/43
UD/43
HYPER
3
2
(66.6%)
_
_
66.6%
13.9 %
2.3 %
_
16.2 %
Normal
22
4
(18.1%)
1
(4.6%)
_
22.7%
HYPO
18
_
_
_
_
23/03/2011
Piercarlo Meinero MD
Urgency Incidence: Statistic Validation
OR correlation between rectal hypersensitivity and Urgency
Pre-op. RST
Patients
TU
PU
SU
DU
OR (95% CI)
OR (95% CI)
OR (95% CI)
OR (95% CI)
Not hypersens.
97
1 (ref)
1 (ref)
1 (ref)
1 (ref)
Hypersens.
30
4.8
10.1
20.6
64.5
(0.9-26.2)
(1.4-71.3)
(1.8-226.2)
(6.9-603.2)
0.07
0.02
0.01
<0.001
p value
OR: Odds RatioCI: Confidential Interval
There is an important correlation between hypersensitivity and Permanent Urgency (p=0.02), between
hypersensitivity and Severe Urgency (p=0.01) and not so important between hypersensitivity and
Temporary Urgency (p=0.07).
As a whole the correlation between Hypersensitivity and Urgency is asbolutely
significant (p>0,001).
23/03/2011
Piercarlo Meinero MD
MFA plan
MFA TEST
RST
cc air
BET
n.v..
Result
FS
30-60
Hypersensitivity
DDV
60-160
Normal
MTV
160-270
Hyposensitivity
m.e.t.
S
NS
BET Result
Positive
Normal
Negative
LMAC
Operatory thatre
Consent
n.v.
< 60 sec.
EPA
Visit MFA
e.t.
cms
Result
MTV
Clinical suspicion:
Other exames;
Diagnosis:
23/03/2011
Piercarlo Meinero MD
Conclusions
The use of the MFA at the first proctological visit
allows:
To perform Rectal Sensation Test in case of minor
pathologies, too;
To suspect attendant diseases;
To foresee postoperative complications;
To avoid hurried surgical decisions;
To assess the correct prolapse extent;
To foresee biofeedback results.
23/03/2011
Piercarlo Meinero MD
MFA Courses
1 day – Place: Rapallo – ECM accredited
[email protected]
www.piercarlomeinero.it
23/03/2011
Piercarlo Meinero MD
Thank you all for attention
23/03/2011
Piercarlo Meinero MD