J. Coloproctol. (Rio J.) vol.35 número1

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Original

Article

The

importance

of

three-dimensional

anorectal

ultrasound

in

the

study

of

patients

with

anal

pain

Doryane

Maria

dos

Reis

Lima

,

Univaldo

Etsuo

Sagae

,

Gustavo

Kurachi

,

Salua

Hamaoui

,

Tomaz

Massayuki

Tanaka

,

Mauro

Willemann

Bonatto

,

Ricardo

Shigueo

Tsuchiya

,

Carlos

Alberto

de

Carvalho

a_{MedicalCourse,FaculdadeAssisGurgacz(FAG),Cascavel,PR,Brazil}

b_{GastroclínicaCascavelLtda.,Cascavel,PR,Brazil}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received14May2014 Accepted12September2014 Availableonline29January2015

Keywords: Analpain

Anorectalultrasound Intersphinctericsepsis

a

b

s

t

r

a

c

t

Objectives: Analpaincanbecausedbyvariousmedicalconditions;theexclusionoforganic causesforpropertreatmentisimportant.Three-dimensionalanorectalultrasoundcan iden-tifyorganiccausesofanalpain.Theobjectiveofthisstudywastoevaluatetheimportanceof three-dimensionalanorectalultrasoundinthedetectionoforganicabnormalitiesinpatients withanalpain.

Methods:Twenty-twopatients(meanage:49years;13women)withchronicanalpainwere enrolledtojoinaprospectivestudybetweenJune2009andJune2011.Acompleteproctology andcolonoscopyexaminationwasnormal.Subsequently,thepatientsunderwent three-dimensionalanorectalultrasound.

Results:Intersphinctericsepsiswasfoundin14patients(63.6%).Twofemalepatients(9.1%) hadanalsphincterinjury,oneofthemwiththepresenceofagradeII rectocele.There wasanincreaseinthethicknessofthesubepithelialtissueinthreepatients(13.6%).Inone patient(4.6%),thepresenceofahypoechoiccircularretrorectal(presacral)cystofthemiddle andlowerrectumwasobserved.Thethree-dimensionalanorectalultrasoundexamination showednoabnormalitiesintwopatients(9.1%).

Conclusion: Thethree-dimensionalanorectalultrasoundisasimple,economical,fastand usefultestforthestudyofanorectaldiseasesandshouldbeincludedintheexaminationof patientswithanalpain,toexcludeorganiccauses.

©2015SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.All rightsreserved.

∗ _{Correspondingauthor.}

E-mail:doryane@gmail.com(D.M.d.R.Lima).

http://dx.doi.org/10.1016/j.jcol.2014.09.002

Palavras-chave: Doranal

Ultrasomendorretal Sepseinteresfincteriana

r

e

s

u

m

o

Objetivos: Adoranalpoderesultarváriascondic¸õesclínicasesefaznecessárioexcluir causasorgânicasparaotratamentoadequado.Aultra-sonografiaanorretaltridimensional (3D-US)podeidentificarcausasorgânicasdedoranal.Oobjetivodesteestudofoiavaliara importânciada3D-USparadetectaranomaliasorgânicasempacientescomdoranal. Métodos: Vinteedoispacientes(médiadeidade:49anos;trezemulheres)comdoranal crônicaforamincluídosemumestudoprospectivoentrejunhode2009ejunhode2011.O exameproctológicocompletoecolonoscopiaforamnormais.Posteriormente,ospacientes foramsubmetidosà3D-US.

Resultados: Sepseinteresfincterianafoievidenciadaemquatorzepacientes(63,6%).Duas pacientes(9.1%)apresentaramlesãodoesfíncteranal,sendoumacompresenc¸ade reto-celegrauII.Oaumentodaespessuradotecidosubepitelialapresentou-seemtrêspacientes (13,6%).Emumpaciente(4,6%),foievidenciadaapresenc¸adecistoretrorretalcircular hipoe-coiconoretomédioeinferior.OexamedeUS-3Dnãoevidenciouanormalidadesemdois indivíduos(9.1%).

Conclusão: Aultra-sonografiaanorretaltridimensionaléumexamesimples,econômico, rápidoeútilnoestudodedoenc¸asanorretaisedeveserincluídonoestudodospacientes comdoranalparadescartarcausasorgânicas.

©2015SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda. Todososdireitosreservados.

Introduction

Chronicanalpaincanbecharacterizedasanoftenintense, poorlydefined,not-irradiatingand,insomecases,lancinating painwithatleastthreemonthsduration.Theprevalenceof anorectalpaininAmericanhouseholdheadswas6.6%,being morecommoninwomen1_{andaccountsfor30–40%ofvisits}

foranalpain.2

Thisconditioncanresultfromavarietyofcausesandmay beassociatedwithproctologic,gynecological,genitourinary, traumatic,neurological or psychologicalchanges.3 _{In most}

patients,athoroughclinicalhistorycharacterizingthenature ofanalpainanddefiningwhetherthereisornota relation-shipwithstraining,inassociationwithathoroughphysical exam,allowsthephysiciantoestablishthediagnosis.Thus, theexclusionoforganiccausesofanorectalpainnot identi-fiedafterathoroughproctologicexaminationisneeded.As anexample,wecanmention:deepperirectal postoperative sepsis,4_{primaryintersphinctericabscess,}5_{hiddensphincter}

injuries, and other organic diseases ofsurgical resolution. Therearealsocasesofanorectalpainoffunctionaletiology suchasproctalgiafugax,elevatorsyndromeandunspecified chronicanorectalpain. Anaccuratediagnosisisneededfor propertreatment.

Anorectalultrasonographyisanimagingdiagnostic tech-niqueindicatedinbenignandmalignantanorectaldisorders.6

Thistechniqueconstitutesanimportantallyinthedetection oforganic causesofanal painwithnochangesinphysical examination.Morerecently,duetothelimitationforviewing imagesinthelongitudinalplane,atransducerthatallowsthe three-dimensionalreconstructionofimageswhichare two-dimensionallyobtainedwasintroduced.7

Withthistypeofultrasound,thephysicalexaminationhas beenenrichedwithaccurateinformationonanalcanaland rectumonseveralplanes,andthistechniquecandemonstrate thesizeandpositionofallanatomicalstructures.

Objective

The aim of this paper is to emphasize the importanceof three-dimensionalanorectalultrasonographyinpatientswith chronicanalpainwithoutchangeintheirphysical examina-tion.

Methodology

Thisisaprospectivestudyconductedduringtheperiodfrom June 2009 to June 2011 in 22 patients with chronic anal pain suspected ofhavingafunctional diagnosis. The aver-ageagewas49years,with13women(59.1%)andninemen (40.9%).

Thisstudycomprisedpatientswithchronicanalpain last-ing more than threemonths.1 _{Thepain wascharacterized}

byhavingdurationfrom15sto20minandwithnorelation tostraining.Inaddition,ourpatientsdidnotrequired med-ication tominimize their symptomsand the pain wasnot disablingfortheirwork.

EAEI

EAI

CAM

CAS EAI

EAE

Anterior

A

B

Posterior

EAE–PR

Fig.1–Presenceofanintersphinctericinflammatory-infectiousprocess(yellowarrows)inthemiddleanalcanal(MAC). EAS,externalanalsphincter;IAS,internalanalsphincter(whitearrows);A,axialsection;B,sagittallongitudinalplane.

fromColoproctologicalService,atGastroclínicade Cascavel Ltda.,byasingleexaminer(DMRL).

Thedeviceused wastype 2050BKMedical® _ultrasound

withafull360◦_{fieldprobe.Afterundergoingbowelpreparation}

withafleetenema2hbeforethetest,thepatientswere exam-inedintheleftlateralposition.Digitaltouchwasperformed and then the transducer was inserted and positioned into theanalcanal.Theimageswereacquiredbytwoautomatic

scans inmen–corresponding tothe anal canalandlower rectum,respectively–andthreeinwomen–corresponding totheanalcanal,lowerrectumanddynamicexamination.8

Theanalcanalscanningwasperformedwiththetransducer at6cmfromtheanalmargin;thedynamicexaminationwas performedat7cmfromtheanalmargin;andthelowerrectum scanningwasheldatapoint10cmfromtheanalmargin.The cube-view3Dimageswereanalyzedintheaxial,transverse,

OI

OI CAS

CAI EAE Anterior

A

B

Posterior

EAE–PR

EAI

CAS EAI

1

1 2

EAI CAI

EAE

EAE

A

Posterior

EAE–PR

Fig.3–Increaseinthethicknessofthesubepithelialtissue(mucosalprolapse)inmiddle(MAC)andupper(UAC)analcanal. A,axialsectioninMAC;B,sagittalsection.

sagittaland diagonalplanes.Thesphincterintegrityinthe anal canal and walls of the rectum and perianorectal tis-suewasevaluated.Theidentificationofasubepithelialtissue thickeningwithmeasurementsexceeding0.3cmmay corre-spondtoamucous-haemorrhoidalprolapse.9_Thismeasure

wasobtainedinthemiddleandupperpartsoftheanalcanal, atthe9and6o’clockpositions.

The sonographic findings indicative of an intersphinc-tericinflammatory-infectiousprocesswerecharacterizedby ahypoechoic,irregular,heterogeneouscavity,oftenwithpoor echoesinside,betweentheexternalandinternalanal sphinc-ters in the middle anal canal, between the internal anal sphincter and the puborectalis muscle in the upper anal canal, and in the ischiorectal fossa in the lower rectum.

EAI

1

3 2

1

EAI

EAE EAE

Vagina

Repouso Repouso

Esforco evacuatorio

A

B

Fig.5–Presenceofahypoechoiccircularimageinmiddleandlowerrectum–retrorectal(presacral)cyst:delimitationofthe cyst(arrows).A,axialsection;B,sagittallongitudinalplane.

Theretrorectalcystwascharacterizedforbeinganirregular, hypoechoic,cysticimagelocatedposteriortothewallsofthe middleandlowerrectum.10_{Theimageobtainedbydynamic}

echodefecographywasconsideredasarectocelewhena differ-enceintheposteriorvaginalwallpositionatrestandduring strainingwasnoted.8_{Sphincterinjurywascharacterizedas}

a hypoechoic interruption of muscle fibers of the internal anal sphincter and a hyperechoic interruption of external sphincter.11

Thefollowingvariableswereassessed:age,gender,parity, andprevioushistoryofanorectaldiseaseand/orsurgery.

Patientswithanalpaincomplaintsandwithproctologic orcolonoscopicfindingswhichwouldjustifythepain,such ashemorrhoids,fissures,fistulae,hypertrophicpapillaeand inflammatoryboweldisease,aswellaspatientswithahistory ofpreviousorificialsurgeryandfemalepatientswithchanges ingynecologicalexaminationswereexcludedfromthestudy.

Results

The results indicated an intersphincteric inflammatory-infectiousprocessoftheupperanalcanalandlowerrectum andinthemiddleanalcanalin14patients(63.6%)(Fig.1).In onepatient,aninternalfistulaopeningat6o’clockpositionin themiddleanalcanalwasfound,suggestingthepresenceof analfistula(Fig.2).

Thethicknessofthesubepithelialtissuewashigherthan normal,suggestingahaemorrhoidalmucousprolapseinthe middleand upperanal canalin threepatients (13.6%)The thicknessofthesubepithelialtissuewashigherthannormal, suggestingthepresenceofahaemorrhoidalmucousprolapse inthemiddleandupperanalcanalinthreepatients(13.6%)

(Fig. 3). Two female patients(9.1%) presentedwithananal sphincterinjury,oneofthembeingintheinternalanal sphinc-terinthepresenceofagradeIIrectocele,andtheotherinthe externalanalsphincterinthedistalandanteriorpartsofthe middleanalcanalnotaccompaniedbyarectocele(Fig.4).

Inonepatient(4.6%),theexaminationrevealedthe pres-ence ofahypoechoiccircularretrorectalcyst inthemiddle andlowerrectum(Fig.5).The3D-USexaminationrevealedno abnormalitiesintwosubjects(9.1%).

Discussion

Ultrasonographyhasawell-definedroleintheevaluationof benignandmalignant anorectaldiseases,becausethis pro-ceduredemonstratespreciselytheanatomicalstructuresthat formtheanalcanal,rectumandperi-anorectaltissues.Inthis study,anorectalchangeswereidentifiedin91.9%ofpatients and adiagnosis ofidiopathic proctalgia wasestablishedin 9.1%.Inastudypublishedin2008,theauthorsidentifiedthe causesofpainin82%ofcases.12_{In2010,anotherstudy}

iden-tifiedspecificorganiccausesofdiseasein49%ofcases.13

Thedifficulties indiagnosingintersphinctericsepsisare welldocumented,thankstotheabsenceofexternalclinical signs suchasswelling,indurationorperianal hyperemia.14

Thus,anearlydiagnosisandeffectivetreatmentofferbetter postoperative functional outcomes.15 _{In this study,}

inter-sphinctericsepsiswasdiagnosedin14patients(63.6%),and the path and internalfistulous orifice were evidenced ina patient.

Beer-Gabel et al.16 _{demonstrated that changes such as}

identified inrelation todefecation was asubepithelial tis-suethickening,suggestingmucous-haemorrhoidalprolapse in 13.6%,and this may be the cause ofanal pain. In two femalepatients,thepresenceofananalsphincterinjurywas evidenced.

Other causes of anal pain that should be considered, despite its low incidence, are perianal endometriosis and perinealorretrorectal tumors.Inonepatient, thepresence of a retrorectal cyst of the middle and lower rectum was evidenced.

Mostofthetime,analpaindoesnotmeanalesionof malig-nantnature,however,itdecreasesthepatient’squalityoflife ifnotdiagnosedandwithout propertreatment.Ultrasound helpstodemonstratethewholeanatomyoftheanalcanal, allowingaclearunderstandingofpossiblecausesofanalpain, hencetheusefulnessofthetest.Thus,functionalcausesare removedfromanatomicalcauses,allowingtheestablishment ofaspecifictherapyforeachcase.

Conclusion

Thethree-dimensionalanorectalultrasoundisasimple, cost-effective,fast and usefulmethod inthe studyofanorectal diseasesandshouldbeincludedinthestudyofpatientswith analpain,withtheaimtoruleoutorganiccauses.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

r

e

f

e

r

e

n

c

e

s

1. BharuchaAE,WaldA,EnckP,RaoS.Functionalanorectal

disorders.Gastroenterology.2006;130:1510–8.

2. SwashM.Chronicperianalpain.In:HenryM,SwashM,

editors.Coloproctologyandthepelvicfloor.London:

Butterworths;1985.p.388–92.

3. CheungO,WaldA.Managementofpelvicfloordisorders.

AlimentPharmacolTher.2004;19:481–95[Review].

haemorrhoidectomy.BrJSurg.1998;85:1522–4.

5.MillanM,García-GraneroE,EsclápezP,Flor-LorenteB,EspíA,

LledóS,etal.Managementofintersphinctericabscesses.

ColorectalDis.2006;8:777–80.

6.TarantinoD,BernsteinMA.Endoanalultrasoundinthe

stagingandmanagementofsquamous-cellcarcinomaofthe

analcanal:potentialimplicationsofanewultrasoundstaging

system.DisColonRectum.2002;45:16–22.

7.KimJC,ChoYK,KimSY,ParkSK,LeeMG.Comparativestudy

ofthree-dimensionalandconventionalendorectalultra

graphyusedinrectalcancerstaging.SurgEndosc.

2002;16:1280–5.

8.Murad-RegadasSM,RegadasFSP,RodriguesLV,EscalanteRD,

SilvaFRS,LimaDMR,etal.Ecodefecografiatridimensional

dinâmica.Novatécnicaparaavaliac¸ãodasíndromeda

defecac¸ãoobstruída(SDO).RevBrasColoproct.

2006;26:168–77.

9.Murad-RegadasSM,RegadasFSP.Ultra-sonografiaanorretal

bietridimensional.In:Murad-RegadasSM,RegadasFSP,

editors.DistúrbiosFuncionaisdoAssoalhoPélvico-Atlasde

Ultra-sonografiaAnorretalBieTridimensional.RiodeJaneiro:

Revinter;2006.p.51–78.

10.Murad-RegadasSM,RegadasFSP.Miscelanias.In:

Murad-RegadasSM,RegadasFSP,editors.Distúrbios

funcionaisdoassoalhopélvico-AtlasdeUltra-sonografia

AnorretalBieTridimensional.RiodeJaneiro:Revinter;2006.

p.342–62.

11.SantoroGA,DiFalcoG.Basicanatomy.In:SantoroGA,Di

FalcoG,editors.Atlasofendoanalandendorectal

ultrasonography.Milán:Springer;2004.p.25–42.

12.PascualI,García-OlmoD,Martínez-PuenteC,

Pascual-MonteroJA.Ultrasoundfindingsinspontaneous

andpostoperativeanalpain.RevEspEnfermDig.

2008;100:764–7.

13.VieiraAM,Castro-Poc¸asF,LagoP,PimentelR,PintoR,Saraiva

MM,etal.Theimportanceofultrasoundfindingsinthestudy

ofanalpain.Ultrasoundfindingsinthestudyofanalpain.

RevEspEnfermDig.2010;102:308–13.

14.OnacaN,HirshbergA,AdarR.Earlyreoperationforperirectal

abscess–apreventablecomplication.DisColonRectum.

2001;44:1469–73.

15.Garcia-AguilarJ,BelmonteC,WongWD,GoldbergSM,Madoff

RD.Analfistulasurgery.Factorsassociatedwithrecurrence

andincontinence.DisColonRectum.1996;39:723–9.

16.Beer-GabelM,TeshlerM,SchechtmanE,ZbarAP.Dynamic

transperinealultrasoundvs.defecographyinpatientswith