for medical education

1. Dr Nabarun Biswas
Registrar surgery
MMCH

2. Pelvic floor disorder
Anterior comp.
Incontinence
Voiding
dysfunction
Posterior comp
Incontinence
Intussusception
Prolapse
Middle comp.
Ant:
Cystocele
Urethro/ cysto-urethrocele
Central:
Uterine Prolapse
Vault prolapse
Post:
enterocele
rectocele
2 common disease: prolapse (multi-
compartmental) & incontinence
Floor:
Dyssynergia
Descend

3. Common
Investigations
Morphological
Assessment
1. Defecograme
CD
DCP
CCD
MR D
2. USG
TPUS
EVUS
EAUS
Functional
assessment
1. Anal manometry
2. BET
3. EMG
4. PNLT
5. Spinal motor
latency test
6. Urodynamic study

4. Morphological
assessment

5. Defecogram
 Indications:
Defecatory disorder
Constipation
Incontinence
 Conventional defecography in gold
slandered for assessing
morphological and functional
status of ano-rectum & pelvic floor
disfunction
 POP in woman may be multicompartmental so DCP arise

6. Steps for
Defecography
• Preparation
• Procedure
• Capturing image
1-3 image /sec
@rest, squeeze
Valsalva & strain

7. Interpretations
• ARA
@rest  95-960 [65-1000]
Squeeze  15-200 sharp
Strain  15-200 obtuse
• ARJ evaluation
Movement (PCL)
• Post. Urethro-vesicle angle
90-1200 = Normal
>1200 = incontinence

8. MR Defecography
• Anatomical detail
• Incidental Dx
• No radiation
• Less physiologic
 Preparation
 Technique
 Interpretation
(HMO System)

11. Ultrasonography
• 2D , 3D mode
• No radiation
• Minimal discomfort
• Cost effective
• Short time
• Wide available

12. • 2D & 3D TPUS
• Mid sagittal view
• Morphological & Functional assessment
• Convex transducer

13. Ant. Comp.
assessment by USG
• By 2D TPUS
• In mid sagittal plane
• @ rest, valsalva
• Bladder wall thickness  up to
5mm NV
• Post void bladder vol
• Bladder neck –symphysis
distance  rest vs Valsalva=25
mm
• Urethral length & U-V angle
90-1200
• Descend of bladder in relation
to symphysis pubis

14. Central comp
assessment by USG
• By 2D TPUS
• Unusual low cervix is iso
echoic
• Uterus : anteverted,
retroverted or enlarged
• Dynamic 2D TPUS
detects uterine prolapse,
vault prolapse.

15. EVUS

16. Posterior comp
evaluation by USG
• By 3D EAUS
• Hyper-echoic external sphincter
• Hypo-echoic internal sphincter

17. Pathological
evaluation
• Stress incontinence
• Urge incontinence
• Fecal /anal incontinence
• Levator ani injury
• Middle / post comp
prolapse

18. Functional
Assessment

19. Anorectal
manometry
& sensory
test
Measure pressure in anus & rectal
ampulla
Types: Air charged M, HR M, HD
M.
Indication: FI, ODS, Constipation,
Anal pain, pelvic floor dyssynergia
Therapeutic: Biofeedback

20. Anorectal
manometry

21. Interpretations:
Resting Pressure
• 80% by external, 20% by
Internal sphincter
• High pressure zone in anal
canal
• Hypotonic rectal pressure 
incontinence

22. Squeeze
pressure
• Voluntary contraction of external
sphincter
• Measures pubo-rectalis status
• Lower in woman & aged

23. Stress/ Cough Reflex

24. Stimulated
evacuation
• ↑ rectal pressure  ↓
anal pressure
• Patient asked to push for
15 sec, 3 times , 30 sec
interval
• In P floor dyssynergia 
paradoxical anal
contraction or spasm

25. Recto-anal inhibitory reflex
• Distension of rectum  contraction of ext spnc 
relaxation Int sphincter
• Mediated by myenteric plexus
• Performed by gradually inflating balloon by 30 ml
of air
• More increase in balloon vol in megacolon
• Absent in: Hirschprung’s, myenteric neuropathy,
rectal reconstruction

26. Rectal sensation
• 1st time patient constantly
feels sensation
• 1st urge
• Maximum tolerated
volume

27. Balloon expulsion test
Ability to retain or expel
feces
Measures fecal
incontinence, Pelvic floor
dyssynergia

28. Neuro-physiological Test:
EMG
• Identify myoelectric activity of
external sp & levator ani
• 3types of electrode used: needle E,
single fiber E & surface E
• Painful & less tolerated
• Detects incontinence & ODS

29. Pudendal nerve
latency test
• Used to measure conduction time of
distal part of pudendal innervation of
Ext Sp
• Normal value = 2 m.sec ± 0.2
• Complimentary technique for patients
with FI, pelvic pain & rectal prolapse

30. Urodynamic study
Urodynamic testing denotes how well the
parts of the lower urinary tracts work to
store and release urine.
Most urodynamic tests focus on how well
the bladder can hold and empty urine.
Urodynamic tests can also show whether
the bladder is contracting when it’s not
supposed to, causing urine to leak.

31. Urodynamic
study includes
• uroflowmetry
• postvoid residual urine
measurement
• cystometric test
• leak point pressure
measurement
• pressure flow study
• electromyography
• video urodynamic tests