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An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female anorectal dysfunction

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Abstract

Introduction and hypothesis

The terminology for anorectal dysfunction in women has long been in need of a specific clinically-based Consensus Report.

Methods

This Report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted on Committee by experts in their fields to form a Joint IUGA/ICS Working Group on Female Anorectal Terminology. Appropriate core clinical categories and sub classifications were developed to give an alphanumeric coding to each definition. An extensive process of twenty rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus).

Results

A Terminology Report for anorectal dysfunction, encompassing over 130 separate definitions, has been developed. It is clinically based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Female-specific anorectal investigations and imaging (ultrasound, radiology and MRI) has been included whilst appropriate figures have been included to supplement and help clarify the text. Interval review (5–10 years) is anticipated to keep the document updated and as widely acceptable as possible.

Conclusions

A consensus-based Terminology Report for female anorectal dysfunction terminology has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

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Notes

  1. In regards to definition of various types of urinary incontinence, the interested reader can refer to (Haylen 2010) [7].

  2. A history of receptive anal intercourse has been shown to increase the risk of anal incontinence [12].

  3. Soiling is a bothersome disorder characterized by continuous or intermittent liquid anal discharge. It should be differentiated from discharge due to fistulae, proctitis, hemorrhoids, and prolapse. Patients complain about staining of underwear and often wear protection.

    • The discharge may cause inflammation of the perineal skin with excoriation, perianal discomfort, burning sensation, and itching,

    It often indicates the presence of an impaired internal sphincter function or a solid fecal mass in the rectum but could also be due to the inability to maintain hygiene due to hemorrhoids.

  4. Rome III criteria for functional constipation:

    1. Must include two or more of the following:

    a. Straining during at least 25 % of defecations.

    b. Lumpy or hard stools in at least 25 % of defecations.

    c. Sensation of incomplete evacuation for at least 25 % of defecations.

    d. Sensation of anorectal obstruction/ blockage for at least 25 % of defecations.

    e. Manual maneuvers to facilitate at least 25 % of defecations (e.g., digitalevacuation, support of the pelvic floor).

    f. Fewer than three defecations per week.

    2. Loose stools are rarely present without the use of laxatives.

    3. Insufficient criteria for irritable bowel syndrome.

    * Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis.

  5. Difficulty evacuating stool, requiring straining efforts at defecation often associated with lumpy or hard stools, sensation of incomplete evacuation, feeling of anorectal blockage/obstruction or manual assistance to defecate (or inability to relax EAS/dyssynergic defecation).

  6. Anorectal prolapse can be due to hemorrhoidal, mucosal, rectal prolapse, or rectal intussusception. These definitions are further explained under “Signs.”

  7. This refers to pain localized to the anorectal region, and may include pain, pressure, or discomfort in the region of the rectum, sacrum, and coccyx that may be associated with pain in the gluteal region and thighs.

  8. Fissure pain during, and particularly after, defecation is commonly described as passing razor blades or glass shards See FN10.

  9. Receptive anal intercourse is associated with increased risk of both any female sexual dysfunction [14], as well as with specifically female sexual arousal disorder with distress [15] (“a persistent or recurrent inability to attain [or to maintain until completion of the sexual activity] an adequate wetness and vaginal swelling response of sexual excitement”). The association of receptive anal intercourse with sexual dysfunction might be due to physiological and/or psychological processes. The psychological factors including emotional development problems [16], poorer mood [17], poorer intimate attachment [18] as well as general dissatisfaction are associated with women’s receptive anal intercourse [19]. Physiologic factors could include that: (1) mechanical stimulation of the anus and rectum during anal intercourse increases hemorrhoid risk; (2) women with hemorrhoidectomy have impaired sexual function; and (3) persons with hemorrhoids who have not yet had hemorrhoidectomy “are more likely to have abnormal perineal descent with pudendal neuropathy.” [20, 21] Thus, pudendal nerve dysfunction could be one mechanism leading to sexual dysfunction, and this might be the case even in the absence of diagnosed haemorrhoids [13].

  10. A history of receptive anal intercourse has been shown to increase the risk of anal incontinence, rectal bleeding, and anal fissure [12].

  11. Unlike dyspareunia (from coitus), it might be normal to experience pain or discomfort during receptive anal intercourse.

  12. This may be accompanied by a finding of decreased anal resting tone (in some cases, the result of anal intercourse)—see under Signs. Damage to the internal anal sphincter is the likely basis for the laxity. Unlike stool passage, receptive anal intercourse is not likely to elicit reflex relaxation of the internal sphincter.

  13. Pruritus ani has been classified into primary and secondary. The primary form is the classic syndrome of idiopathic pruritus ani. The secondary form implies an identifiable cause or a specific diagnosis.

  14. With perianal hematomas, the lump may be anywhere around the anal margin and may be multiple. Pilonidal sinuses are usually a small mid-line pit with epithelialized edges.

  15. Figure used from Pelvic floor dysfunction document [7] (Fig. 1a and b).

  16. A transverse defect rectocele occurs simply by a detachment of the perineal body from the rectovaginal fascia. The hammock of rectovaginal fascia supporting the rectum remains intact but separates from the perineal body. A midline vertical defect is created by a midline separation of the rectovaginal fascia, and a separation of the rectovaginal fascia can occur from it’s lateral attachments. Rectoceles are more commonly situated in the mid to distal aspect of the posterior vaginal wall.

  17. Symptoms of levator ani syndrome are painful rectal spasm, typically unrelated to defecation, usually lasting >20 min. The pain may be brief and intense or a vague ache high in the rectum. It may occur spontaneously or with sitting and can waken the patient from sleep and occurs more often on the left. The pain may feel as if it would be relieved by the passage of gas or a bowel movement. In severe cases, the pain can persist for many hours and recur frequently. During clinical evaluation: a dull ache to the left 5 cm above the anus or higher in the rectum and a feeling of constant rectal pressure or burning. Physical examination can exclude other painful rectal conditions (e.g., thrombosed hemorrhoids, fissures, abscesses, scarring from previous surgery). Physical examination is often normal, although tenderness or tightness of the levator muscle, usually on the left, may be present. Occasionally the cause can be low back disorders. Coccydynia (coccygodynia) is complaint of pain and point tenderness of the coccyx (this is NOT anorectal pain).

  18. Proctalgia fugax most often occurs in the middle of the night and lasts for seconds to 20 min. During an episode, which sometimes occurs after orgasm, the patient feels spasm-like, sometimes excruciating pain in the anus, often misinterpreted as a need to defecate. Because of the high incidence of internal anal sphincter thickening with the disorder, it is thought to be a disorder of the internal sphincter or that it is a neuralgia of pudendal nerves. It tends to occur infrequently (once a month or less). Like all ordinary muscle cramps, it is a severe, deep rooted pain. Defecation can worsen the spasm, but may relieve it [112], or provide a measure of comfort. The pain might subside by itself as the spasm disappears on its own, or may persist or recur during the same night. Patients with proctalgia fugax are usually asymptomatic during the anorectal examination, leaving no signs or findings to support the condition, which is based on symptoms by history taking, diagnostic criteria, described above, and the exclusion of underlying organic disease (anorectal or endopelvic) with proctalgia [113].

  19. The condition is also known as pudendal neuropathy, pudendal nerve entrapment, cyclist’s syndrome, pudendal canal syndrome, or Alcock’s syndrome. The Nantes criteria [13] includes:

    1. 1.

      Pain in the anatomical region of pudendal nerve innervation.

    2. 2.

      Pain that is worse with sitting.

    3. 3.

      No waking at night with pain.

    4. 4.

      No sensory deficit on examination.

    5. 5.

      Relief of symptoms with a pudendal block.

    Primary symptoms of PN include:

    1. a)

      Pelvic pain with sitting that may be less intense in the morning and increase throughout the day. Symptoms may decrease when standing or lying down. The pain can be perineal, rectal or in the clitoral/penile area; it can be unilateral or bilateral.

    2. b)

      Sexual dysfunction. In women, dysfunction manifests as pain or decreased sensation in the genitals, perineum or rectum. Pain may occur with or without touch. It may be difficult or impossible for the woman to achieve orgasm.

    3. c)

      Difficulty with urination/defecation. Patients may experience urinary hesitancy, urgency and/or frequency. Post-void discomfort is not uncommon. Patients may feel that they have to “strain” to have a bowel movement and the movement may be painful and/or result in pelvic pain after. Constipation is also common among patients with PN. In severe cases, complete or partial urinary and/or fecal incontinence may result.

    4. d)

      Sensation of a foreign object being within the body. Some patients will feel as though there is a foreign object sitting inside the vagina or the rectum.

    It is important to note PN is largely a “rule out” condition. In other words, because its symptoms can be indicative of another problem, extensive testing by physical examination, assessment by touch, pinprick, bimanual pelvic palpation with attention to the pelvic floor muscles, in particular the levator and obturator muscles, tenderness of the bladder and sacrospinous ligaments are required to ensure that symptoms are not related to another condition. Maximum tenderness, or a trigger point can be produced by applying pressure to the ischial spine. Palpation of this area can reproduce pain and symptoms as a positive Tinel’s sign [114].

    As PN is a diagnosis of exclusion, other conditions that should be excluded include coccygodynia, piriformis syndrome, interstitial cystitis, vulvodynia, vestibulitis, chronic pelvic pain syndrome, proctalgia, anorectal neuralgia, pelvic contracture syndrome/pelvic congestion, proctalgia fugax, or levator ani syndrome.

    In addition to eliminating other diagnoses, it is important to determine if the PN is caused by a true entrapment or other compression/tension dysfunctions. In almost all cases, pelvic floor dysfunction accompanies PN. Electrodiagnostic studies will help the practitioner determine if the symptoms are caused by a true nerve entrapment or by muscular problems and neural irritation.

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Acknowledgments

We gratefully acknowledge contributions from Dr Helen Frawley, Beth Shelley following ICS (V29 Jan 2015) IUGA website presentation of Version 30 (Aug15, Dr Alexis Schizas and Kari Bo at ICS Montreal (V33 8Oct15).

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Authors and Affiliations

  1. Urogynaecology and Pelvic Floor Reconstruction Unit, Croydon University Hospital, London Road, Croydon, Surrey, CR7 7YE, UK

    Abdul H. Sultan

  2. Princess Anne Hospital, Southampton, UK

    Ash Monga

  3. University of Melbourne, Mercy Hospital for Women, Monash Health, Melbourne, Victoria, Australia

    Joseph Lee

  4. University College Hospital, London, UK

    Anton Emmanuel

  5. Kings College London, London, UK

    Christine Norton

  6. Regional Hospital, Treviso, Italy

    Giulio Santoro

  7. Cleveland Clinic Foundation, Cleveland, OH, USA

    Tracy Hull

  8. Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands

    Bary Berghmans

  9. Department of General Anthropology, Charles University, Prague, Czech Republic

    Stuart Brody

  10. University of New South Wales, Sydney, New South Wales, Australia

    Bernard T. Haylen

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  1. Abdul H. Sultan
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  2. Ash Monga
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  3. Joseph Lee
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  4. Anton Emmanuel
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  5. Christine Norton
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  6. Giulio Santoro
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  7. Tracy Hull
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  10. Bernard T. Haylen
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Corresponding author

Correspondence to Abdul H. Sultan.

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Conflict of interest

Dr. Sultan has patent on anal sphincter blocks with royalties paid to the Mayday Childbirth Charity fund. He described the Sultan Classification of third degree tears and runs hands-on workshops on Perineal and Anal Sphincter Trauma (www.perineum.net.; A Monga: reports being Consultant for Gynecare and AMS and Speaker for Astellas and Pfizer and advisor for Allergan.; Dr. Lee reports personal fees from AMS, personal fees from BSCI, during the conduct of the study; Dr. Emmanuel served on advisory boards for Coloplast, Shire, Pfizer. Honoraria for talks from these companies as well as Ferring and Astra-Zeneca; Dr. Norton reported Consultancy for SCA, Coloplast, Shire, Dr Falk, Clinimed; Dr. Santoro has nothing to disclose; Dr. Hull has nothing to disclose; Dr. Berghmans has nothing to disclose; Dr. Brody has nothing to disclose; Dr. Haylen has nothing to disclose.

Additional information

This document is being published simultaneously in Neurourology and Urodynamics (NAU) and the International Urogynecology Journal (IUJ), the respective journals of the sponsoring organizations, the International Continence Society (ICS) and the International Urogynecological Association (IUGA).

Standardization and Terminology Committees IUGA* & ICS# - Joseph Lee*, Bernard T. Haylen*, Ash Monga#, Bary Berghmans#

Joint IUGA/ICS Working Group on Female Anorectal Terminology - Abdul H. Sultan, Ash Monga, Joseph Lee, Anton Emmanuel, Christine Norton, Giulio Santoro, Tracy Hull, Bary Berghmans, Stuart Brody, Bernard T. Haylen

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.23055.

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Sultan, A.H., Monga, A., Lee, J. et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female anorectal dysfunction. Int Urogynecol J 28, 5–31 (2017). https://doi.org/10.1007/s00192-016-3140-3

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