AIM: To compare defecographic abnormalities in symptomatic men and women and to analyze differences between men and age- and symptom-matched women.

METHODS: Sixty-six men (mean age: 55.4 years, range: 20-81 years) who complained of constipation and/or fecal incontinence and/or pelvic pain underwent defecography after intake of a barium meal. Radiographs were analyzed for the diagnosis of rectocele, enterocele, intussusception and perineal descent. They were compared with age- and symptom-matched women (n = 198) who underwent defecography during the same period.

RESULTS: Normal defecography was observed in 22.7% of men vs 5.5% of women (P < 0.001). Defecography in men compared with women showed 4.5% vs 44.4% (P < 0.001) rectocele, and 10.6% vs 29.8% (P < 0.001) enterocele, respectively. No difference was observed for the diagnosis of intussusception (57.6% vs 44.9%). Perineal descent at rest was more frequent in women (P < 0.005).

CONCLUSION: For the same complaint, diagnosis of defecographic abnormalities was different in men than in women: rectocele, enterocele and perineal descent at rest were observed less frequently in men than in women.

Constipation, fecal incontinence and pelvic pain require meticulous evaluation because therapy can be effective and help patients to lead a fuller life. Radiographic dynamic rectal examination (defecography) is a valuable method to assess evacuation disorders[1-5]. This method provides precise information on anorectal and pelvic floor functions[6-8]. It can be used to evaluate efficiently defecation disorders after clinical examination for the exploration of constipation, pelvic pain and anal incontinence[9-13].

Posterior pelvic floor disorders are common and well known in women, and some are related to obstetrical consequences. Little is known about gender influence in symptomatic patients investigated by defecography[14,15]. Men can also complain of constipation, fecal incontinence and pelvic pain, and these symptoms need the same careful evaluation because they may need specific therapy[16].

The purpose of our study was to compare prevalence of defecographic abnormalities in men and age- and symptom-matched women.

Constipation, fecal incontinence and pelvic pain were present in 69%, 27% and 56% of our male patients, respectively. These symptoms could be isolated (53%) or associated (Figure 1). The more frequent association was constipation and pelvic pain (33%).

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Figure 1 Defecography in men: distribution with regard to the combination of symptoms (constipation and/or incontinence and/or pain). 0: Absence; 1: Presence.

Defecography could be satisfactorily performed in all patients and all examinations could be analyzed fully with the above-described criteria. In men, 22.7% of the defecography procedures were normal versus 5.5% in women (P < 0.001).

Defecography in men showed intussusception in 38 patients (57.6%), enterocele in seven (10.6%), and rectocele in three (4.5%). Defecography in women showed intussusception in 89 patients (44.9%), enterocele in 59 (29.8%), and rectocele in 88 (44.4%). There was a significantly higher proportion of rectocele and enterocele in matched women (Figures 2 and 3). There was no statistically significant difference for the diagnosis of intussusception.

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Figure 2 Results of defecography with regard to rectocele, intussusception and enterocele in men and women. Rectocele: P < 0.001, Enterocele: P < 0.005, Intussusception: NS.

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Figure 3 Dynamic imaging during evacuation showed an enterocele (black arrow) associated with a rectocele (white arrow).

Distance between the pubococcygeal line and the anorectal junction at the three positions (rest, squeeze and strain) was significantly different between men and women, with a lower position of the perineum in women regardless of position (P < 0.001) (Figure 4). There was a greater incidence of perineal descent at rest in women compared with men (P < 0.005) (Figure 5). There was no difference between men and women for the diagnosis of perineal descent at straining.

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Figure 4 Distance between the pubococcygeal line and the anorectal junction at rest, squeeze and strain in men and women. P < 0.001.

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Figure 5 Percentage of men and women with perineal descent at rest. P < 0.005.

Defecography is used commonly in women, but only a few procedures are carried out in men. In our department, men represented < 10% of all defecography procedures. To the best of our knowledge, no specific study of defecography has been carried out to explore the gender difference in the diagnosis of defecographic abnormalities. The pairing of our case-matched study was done for age and symptoms, with one man for three matched women, as is usual in this type of study. It allowed us to establish any sex difference in the prevalence of defecographic abnormalities.

Intussusception is very common in both sexes (approximately half of patients undergoing defecography)[7,8]. We did not observe any sex difference in prevalence. Enterocele and rectocele were more common in matched women. This could be explained by obstetrical anteriority (vaginal delivery or hysterectomy). The consequences of obstetric damage on the perineum are well known[18,19]. Enterocele is also more frequent after hysterectomy[20]. Rectocele is diagnosed 10 times more frequently in women, and appears to be characteristic of the female population. Rectocele has been reported previously as being uncommon in men[15]. Chen et al[15] have reported a prevalence higher than ours (17% vs 4.4%), and a frequent association between rectocele and prostatectomy (40%). We did not assess the history of all patients, but this difference could be explained by the higher mean age of the patients in the study of Chen et al[15] (72.4 years) than in our study (55.4 years), because prostatectomy is more likely in older patients.

The distance between the pubococcygeal line and the anorectal junction, which determines the position of the perineum, was greater in women for the three positions (rest, squeeze and strain). As a consequence, there was a gender difference for the diagnosis of perineal descent at rest. There was no such difference for perineal descent at straining. This raises the question that the normal level of the perineum could be different in both sexes. However, our study concerned only symptomatic patients and this needs to be investigated in control subjects. No sex-related definition of pelvic floor disorders was established, therefore, our diagnostic criteria were those commonly used, which means those used in women. However, new criteria for the diagnosis of perineal descent at rest in men could probably be defined. The same question can also be raised in elderly patients, for whom diagnostic criteria could also be adapted[21].

Determination of the clinical value of defecographic abnormalities is also difficult and remains a subject of debate[22-26]. Defecographic abnormalities have been shown not to be symptom-related[12]. This study confirmed this finding, because there were gender differences among symptom-matched patients. Interpretation should be cautious because radiographic changes can be demonstrated in healthy subjects of various ages[27,28]. Interobserver agreement is good for rectocele and enterocele[29] but appears insufficient for perineal descent[25]. Different methods for measuring parameters, especially perineal descent, have been described, with controversy as to which is the most accurate, and with little agreement[26,30,31]. New examinations are also possible, such as magnetic resonance defecography, to assess pelvic floor disorders[32,33].

In conclusion, defecography is a potential adjunct to clinical evaluation of men with constipation, fecal incontinence or pelvic pain. With symptoms equal, some defecographic abnormalities are sex-related: rectocele, enterocele and perineal descent at rest were observed less frequently in men.