Case contributed by Vikas Shah
Diagnosis probable


Difficult defecation. Feels a bulge.

Patient Data

Age: 30 years
Gender: Female

MRI proctogram


Structural findings:
No muscular defects. Normal appearances of the pelvic viscera.

Dynamic findings: 
Measurements obtained using the PCL system at maximal straining are as follows:
Bladder neck: 5 mm above line (within normal limits)
Cervical neck: 17 mm above line (within normal limits)
Anorectal junction: 44 mm below line (mild anorectal junction descent)
Rectocele: 27 mm in depth (moderate sized anterior rectocele)

There is no evidence of gel being expelled during the examination. There is mild anorectal junction descent and a moderate sized anterior rectocele seen on straining. No evidence of intussusception or prolapse. No evidence of an enterocele.

In summary:
Descent of predominantly the posterior compartment during straining with formation of a moderate sized anterior rectocele.
No gel is passed during the examination and overall appearances suggest anismus.

Case Discussion

An anatomic problem (rectocele, accounting for the feeling of a bulge) can co-exist with a functional problem (anorectal dyssynergy or anismus - paradoxic pelvic floor spasm during attempted evacuation).

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