1. SYB: Defecogram By BorkoKereshi, MSIII

2. The Case • 32 year old female with a history of: • Chronic constipation • Straining • Irritable Bowel Syndrome

3. Defecogram: The Technique • Approximately 1 hour before the study the patient ingests one bottle of thin barium to visualize the small bowel for possible enterocele. • Barium paste is instilled into the rectum. • A small metallic marker is placed on the skin near the anus. • The patient is imaged in the lateral projection during the following maneuvers…

4. The 7 Steps of a Defecogram • 1: Rest • 2: Cough • 3: Squeeze • 4: Valsalva • 5: Evacuation • 6: Post-evacuation valsalva • 7: Post-evacuation rest

5. Rest

6. Cough no incontinence during coughing

7. Squeeze appropriate motion of the anorectal angle during the squeeze

8. Valsalva appropriate motion of the anorectal angle during the valsalva maneuver

9. Evacuation

10. Evacuation Any abnormalities noted?

11. Evacuation Any abnormalities noted?

12. Anterior Rectocele

13. Evacuation Any other abnormalities noted?

14. Evacuation

15. Puborectalis Dyskinesia • contraction of the puborectalis during evacuation (left arrow in preceding image) • Additionally, there is contraction of the anal sphincter during evacuation consistent with sphincter dyskinesia (right arrow)

17. Post-evacuation valsalva

18. Post-evacuation rest Small post void residual

19. The patient required multiple efforts of Valsalva and squeeze to evacuate the barium. • This impaired contraction is highly predictive of anismus • Anismus: malfunction of the external anal sphincter and puborectalis muscle during defecation • More common in women • Sometimes associated with sexual abuse

20. References • LEROI A.-M. ; BERKELMANS I. ; DENIS P. ; HEMOND M. ; DEVROEDE G. Anismus as marker of sexual abuse : consequences of abuse on anorectal motility. Digestive diseases and sciences. ISSN 0163-2116. vol. 40, no7, pp. 1411-1416, 1995 • healthlibrary.epnet.com • www.aboutincontinence.org