Analysis of Rhythmic Rectal Contractions during Filling
Cystometry in Women
Françoise A. Valentini, Brigitte G. Marti, Gilberte Robain, Pierre P. Nelson
UMRS 731 (FAV, GR), INSERM / Université Pierre et Marie Curie (Université Paris 6), Paris, France and Service de Médecine Physique et Réadaptation (FAV, BGM, GR, PPN), Hôpital Charles Foix, Ivry-sur-Seine, France
ABSTRACT
Purpose: Rhythmic or random rectal contractions independent of bladder activity are frequently observed during cystometry and usually attributed either to a neurological disease, or to ageing. The aim of our study was to search for an association
RIUK\WKPLFUHFWDOFRQWUDFWLRQV55&VZLWKDVSHFL¿FORZHUXULQDU\WUDFWV\PSWRPRUDQGDQXURG\QDPLFGLDJQRVLV Materials and Methods: The population consisted of 534 consecutive women with lower urinary tract symptoms and
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Results:55&VZHUHREVHUYHGLQSDWLHQWVZLWKQRGLIIHUHQFHLQQHXURORJLFDOVWDWXVRUDJHQRQ1'DQG\ 1'DQG\3DWLHQWVZLWK55&VZHUHVLJQL¿FDQWO\ROGHUWKDQWKHQHJDWLYHSRSXODWLRQS 55&VKDG DORZIUHTXHQF\PLQWKHLUDPSOLWXGHZDVFP+2LQSDWLHQWV55&VZHUHDVVRFLDWHGZLWKXUJHQF\
patients) whatever the neurological status and with detrusor overactivity only in the neurological patients.
Conclusions:RRCs cannot be considered as artefactual events during cystometry in women, occur in the older population,
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should prompt the physician to look at the possible causes of urgency (colonic or bladder).
Key words: urodynamics; rectum; urinary tract diseases; women
Int Braz J Urol. 2009; 35: 475-83
INTRODUCTION
Rhythmic or random rectal contractions, in dependent of bladder activity are frequently observed
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Recently, it has been found that rectal contractions occur more frequently in males with benign prostatic
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ous motor activity of the rectum (isolated contraction
or sequences of contractions) has been observed and well described during prolonged manometric record ings in both symptomatic and asymptomatic patients (4,5).
The aim of this retrospective study was to review consecutive multichannel urodynamic record ings of women with demonstrated rhythmic rectal contractions (RRCs) in order to determine if there
MATERIALS AND METHODS
The population consisted of 534 consecu
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and nocturia) and voiding symptoms.
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sclerosis, lumbar disc injury, etc. Exclusion criteria
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ous colorectal surgery, rectocele and isolated lower urinary tract pain.
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(normal saline at room temperature) until maximum bladder capacity in a sitting position. Vesical and urethral pressures were recorded using a triple lumen
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the balloon was inserted at 5 cm of the anal verge.
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then the urethral catheter was inserted. Recordings began about 5 minutes after the insertion. Transmis
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independent of the total vesical pressure and indepen dent of respiratory movements.
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attention was given to symptoms of urgency (with
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evaluated from bladder diary and general interroga
tion, and to detrusor overactivity (uninhibited detrusor
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Each study was reviewed independently by
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study needed to be considered univocally positive by both researchers. )RUVWDWLVWLFDODQDO\VLVZHXVHG6WXGHQW¶VW WHVWDQGFKLVTXDUHWHVWZLWKSFRQVLGHUHGWR LQGLFDWHVLJQL¿FDQFH RESULTS $PRQJWKHSDWLHQWVPHDQDJH\HDUV UDQJHWR\HDUVKDGDUK\WKPLF rectal activity. 2IWKHSDWLHQWVZLWKQRKLVWRU\RIQHXUR ORJLFDOGLVHDVHH[KLELWHG55&VFRPSDUHG WRWKHRIWKHSDWLHQWVZLWKDKLVWRU\
of neurological disease. The neurological disease was suprapontine lesion in 5 patients, incomplete spinal
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age was 65.5 r\HDUVLQWKHQRQ1'JURXSFRP
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increase in RRCs incidence with age in our population while the neurological disease incidence is stable or slightly reduced.
RRCs had a low very stable frequency in the
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RRCs of same characteristics (frequency and
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of the onset, the duration and the end of RRCs during cystometry.
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bladder syndrome and detrusor overactivity.
Comparison with the negative population
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,VRODWHG VWUHVV XULQDU\ LQFRQWLQHQFH ZDV REVHUYHGLQRQO\QRQ1'SDWLHQWVPHDQ Figure 1 – Analysis of the entire population (534 female patients). Left: incidence of rhythmic rectal contractions with age. Right: incidence of neurological disease with age.
Figure 3 –([DPSOHRIDSDWLHQWZKRKDGUK\WKPLFUHFWDOFRQWUDFWLRQVGXULQJDOOWKH¿OOLQJF\VWRPHWU\
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COMMENTS
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cordings and of Enhörning hypothesis to evaluate the abdominal pressure during urodynamics (detrusor pressure equals vesical pressure minus rectal pressure) only few urodynamicists have paid attention to or
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multichannel urodynamic testing, both rhythmic and
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analyzed the rhythmic rectal contractions and not the
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contractions and bursts of phasic motor activity in
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which does not allow for an accurate study of random
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female population.
RRCs had a low very stable frequency as if produced by a pacemaker, which led us to compare it with the periodic activity of the gastrointestinal tract. Rhythmic rectal activity has been previously
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tal pressure was recorded using a perfused urethral catheter and waves were of higher amplitude (mean
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of this periodic motor activity remain either lacking
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proportion of the population with RRCs despite the use to measure the rectal pressure of a punctured balloon, which prevents pressure artifacts arising from contact of the catheter with the rectum wall. That rectal activity is independent of the neurological
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periodic rectal motor activity is supposedly triggered
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zation for bladder to bowel and bowel to bladder. That phenomenon may account for chronic pelvic
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research (15) have demonstrated the convergence of bladder and colon sensory innervations at the primary afferent level. Therefore, one can consider the role of
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tion including patients with spinal cord injury and analyzing both rhythmic and random rectal contrac tions, found respectively when comparing patients with a history of neurological disease vs. patients
Table 1 – Incidence of urge syndrome (overactive bladder - OAB) and demonstrated urodynamic detrusor overactivity (DO) in the population with rhythmic rectal contractions.
Non-ND1 NDSWV p Value
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that the physiopathology of voiding disturbances due to a neurological condition is only well characterized in cases of complete spinal cord lesion.
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small studied group and probably their older popu
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the consequence of changes in muscarinic receptor
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overproduction of acetylcholine from the rectum mucosa could be proposed in elderly, leading to
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nomenon is rhythmic.
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gency is frequently associated with RRCs whatever the neurological status and is more frequent than
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detrusor overactivity during the cystometry is more frequently associated with RRCs in patients with a history of neurological disease. Concerning that last result we have to take into account that several central nervous system disorders are associated with
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CONCLUSION
RRCs cannot be considered as artefactual
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ics due to their involvement in the detrusor pressure calculation. The rhythmic character of the contrac tions is consistent with the existence of an oscillator. RRCs occur in the older population, are frequently
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the population (whether or not there is a history
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history of neurological disease detrusor overactiv
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physician to look at possible causes of urgency and
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the fore the role of ageing and possibly of the com mon neurologic innervation of lower urinary and gastrointestinal tracts in the occurrence of rhythmic rectal contractions.
CONFLICT OF INTEREST
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REFERENCES
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tractions noted on multichannel urodynamics.
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of rectal contractions during multichannel urody
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tractions occur during multichannel urodynamic
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Evidence of internal anal sphincter contractions
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variations in patterns from esophagus to colon.
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plications for the overlap of chronic pelvic pain
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bladder and colon sensory innervation occurs
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nervous system involvement in overactive blad
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Accepted after revision: March 12, 2009
Correspondence address:
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EDITORIAL COMMENT
This is an excellent paper that clearly establish that rhythmic rectal contractions (RRCs) and is of clinical
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we have seen but were always sort of shy to speak up
because other experts may not believe us. However, since
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EDITORIAL COMMENT
This interesting study reported the rhythmic rectal contractions (RRCs) during a urodynamic study in women with lower urinary tract symptoms
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older than those without RRCs. RRCs were also noted to associate with urgency symptoms, but RRCs were associated with occurrence of detrusor overactivity
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during urodynamic study especially in patients with neurogenic voiding dysfunction. Convergence of the bladder and distal colon sensory innervation had been shown in rat model at dorsal root ganglion neurons.
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in the overlap of pelvic pain disorders (1). Because
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arc in sacral cords, therefore, RRCs can be regarded
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through inserting rectal catheter or urethral catheter.
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for a longer period, RRCs could disappear. The authors might observe the disappearance of RRCs
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is observed after a longer period of rest, we should wait for the disappearance of RRCs before starting the urodynamic study to ensure a correct subtracted detrusor pressure.
The results of this study also found a higher incidence of RRCs in older population although there
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that the urothelium is involved in sensory mechanisms
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mucosa, acetylcholine and adenosine triphosphate production from urothelium increased in older patients
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in rat bladder can block muscarinic receptors in blad
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have overproduction of acetylcholine in the mucosa of rectal wall, which might also result in spontaneous contractions through stretching of the rectal wall after
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sible that the elderly women have a higher incidence of chronic constipation, which in turn causes frequent RRCs in response to rectal stimulation by the rectal catheter.
The bladder and rectum are located at the convergence area in the sacral cord. The sensation of one organ (bladder) can be induced by stimulating the
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and that RRCs may be a valuable parameter to help us to help our patients with pelvic diseases.
REFERENCE
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other organ (rectum). Therefore, rectal stimulation might evoke sensory response (urgency sensation) or
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urgency sensation during urodynamic study. There fore, it is not surprising that occurrence of RRCs is associated with urgency sensation in overall patients
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The clinical implication of RRCs might be
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who have a hyperactive rectum during natural bladder
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patients with chronic constipation and overactive bladder symptoms due to this hyperactive rectum
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this study and the possible mechanism of RRCs, we should not consider RRCs as artefactual events during
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tients in this study) during the urodynamic study, the
disordered rectum might be considered as the origin
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REFERENCES
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Dr. Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital and
