Examination of anorectal angle and pubococcygeal line in adults with anal area diseases and defecation irregularities by using magnetic resonance images

In our study, we aimed to investigate the importance of pelvic floor muscles in individuals with anal area diseases and defecation irregularities. Musculus puborectalis surrounds the anus like a ring, narrows the anorectal angle (ARA) by contracting in the Valsalva phase of defecation, and relaxes in the final phase of defecation, allowing stool to pass out. In this process, the pelvic floor should be mobilized to less than 2 cm and the anorectal angle change between defecation phases should not be more than 20 degrees. On magnetic resonance images (MRI), the pubococcygeal line (PCL) represents the level of the pelvic floor. ARA, PCL and the distance between ARA and PCL were measured retrospectively on 392 images patients over 18 years of age who underwent lower abdomen MR (Sagittal, T2 sequence) defecography with complaints of fecal incontinence, chronic constipation, anal fissure, haemorrhoids, anal abscess, anal and perianal fistula. ARA was calculated by measuring the angle between the midline of the anal canal and the line tangent to the posterior wall of the rectum. PCL was calculated by drawing a line from the lower border of the symphysis pubis to the last coccygeal joint. Then, the distance between the PCL and the anorectal junction was measured. The measurements were repeated at rest, valsalva and final phase of defecation. Patients were grouped according to World Health Organization's age classification and the average age of childbirth and menopause determined by Turkish Statistical Institute. In the all patients, the ARA was not sufficiently constricted in valsalva, and the angle was wider in women in all phases of defecation. The ARA was wider at rest in patients aged 65 and over, and in the last phase of defecation in patients aged 45-64 compared to other age groups. In all phases of defecation, PCL was longer in women and in the 45-64 age group than in other age groups; pelvic floor descent in the valsalva and final phase was greater in women and in the 45-64 age group. Our results showed that pelvic floor insufficiency is more advanced in the postmenopausal period. Pelvic floor should be evaluated in anal area diseases and pelvic floor rehabilitation should be included in the treatment program. Key words: Constipation, Fecal Incontinence, Anus Diseases, Anorectal Angle, Pubococcygeal Line