Evacuation proctography

Last revised by Andrew Murphy on 23 Mar 2023

Evacuation proctography (defecography) is a fluoroscopic technique to evaluate pelvic floor prolapse. The technique traditionally involves fluoroscopy and barium, but an analogous MRI technique has also been developed (see: MR defecating proctography).

  • incomplete or obstructed defecation / constipation
  • pelvic floor disorder
  • rectal prolapse
  • fecal incontinence
  • postoperative rectum (e.g. coloanal anastomosis)
    • caution should be exercised before loading and stressing an anastomosed rectum

Pre-procedural bowel preparation is optional.

Further optional steps are opacification of the vagina and small bowel, to identify movement of these structures in relation to the rectum during defecation. Men require only opacification of the rectum.

  • vagina 
    • amount of contrast varies between institutions, but 5 mL is used at some
    • barium should be more viscous than oral barium
    • not performed if patient has never been sexually active
  • small bowel
    • 500 mL of barium orally
    • wait 30-60 minutes
    • if not at terminal ileum on a scout radiograph, additional 200 mL of barium and another 30-60 minutes

The fluoroscopy table should be able to accommodate a special commode for the purpose of receiving evacuated rectal barium.

  • patient is first in left lateral decubitus position
    • 2-4 x 60 mL of thick barium paste is introduced into the rectum with a large bore soft catheter (Miller catheter) and the 60 mL syringes
    • barium may be mixed with breadcrumbs, cornflour or porridge powder to form a solution with stool-like consistency (neostool)
    • if the patient has an urge to defecate, the instillation of contrast can cease
  • spot lateral images of the patient at rest in the left lateral decubitus position
    • knees are drawn up in this position, as if the patient were sitting
  • patient is positioned on the commode / defecography chair and a right lateral view of the seated patient is readied
    1. spot image of the patient at rest
    2. optional cine and spot images of the patient "lifting" their rectum (Kegel maneuver)
    3. optional cine and spot images of the patient straining as if they were about to defecate, but not actually defecating
    4. then, finally, the patient should "go like they would go at home" and spot and cine images are taken while the patient evacuates their rectum
    5. a post-evacuation image with straining should be obtained to look for retained material or enterocoele

It should always be remembered that, even if this procedure is routine for the radiologist and technician, this is a highly invasive and sensitive test for the patient. The patient should be given maximum privacy at all times.

In evaluating evacuation proctography images, the key reference line is drawn from the tip of the coccyx to the lower border of the pubic ramus. Ascent and descent of various structures are measured in relation to this line.

In evaluating rectal motion, one measurement often used is the change in the anorectal angle (ARA). This angle is formed by the intersection of a line parallel to the anal canal and a line parallel to the posterior rectum. The change in the anorectal angle is an indirect indication of the strength of the puborectalis muscle.

  • during straining (increased intra-abdominal pressure), the pelvic floor descends a few centimeters
  • during evacuation, the anorectal angle becomes much more obtuse and the anorectal junction descends (<3.5 cm, usually to the level of the ischial tuberosities)
    • there is a wide range of normal for both the rest and evacuation angles, but 90-95° at rest and 135° at evacuation is not unreasonable
    • loss of puborectalis sling impression on the posterior wall of the distal rectum

This is an example of normal evacuation on a proctogram study.

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Cases and figures

  • Case 1: grade III intussusception and rectocoele
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  • Case 2: grade IV intussusception
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  • Case 3: grade V prolapse
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  • Case 4: grade V prolapse
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  • Case 5: anismus
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