Diagnostic Defecography

Procedure Overview

The American College of Radiology recommends defecography to diagnose structural and functional abnormalities causing chronic constipation, fecal incontinence, or pelvic floor dysfunction, with the ability to detect clinically occult findings such as enteroceles or sigmoidoceles in approximately one-third of patients with posterior vaginal wall bulging 1, 2, 4
Defecography can identify structural abnormalities including rectocele, enterocele, sigmoidocele, rectal intussusception, and rectal prolapse, as well as functional disorders like pelvic floor dyssynergia and impaired evacuation 1, 2, 3

Defecography has a higher sensitivity for detecting rectoceles (94%) and enteroceles (35%) compared to physical examination, which detected only 7% of rectoceles and 51% of enteroceles seen on fluoroscopic defecography 1, 4
Fluoroscopic defecography demonstrates excellent correlation for internal rectal prolapse (88% sensitivity) and good agreement for full-thickness rectal prolapse, rectocele, and peritoneocele (83% sensitivity) 1, 4
MR defecography shows moderate to good correlation with surgical findings for most structural abnormalities and superior detection of enteroceles compared to physical examination (detects 70% more cases) 6, 7

The American College of Radiology suggests that oral contrast administration and rectal instillation of thick barium paste are essential for fluoroscopic defecography, while rectal contrast gel instillation is necessary for MR defecography 2, 4, 6
Complete rectal emptying is crucial for detecting enteroceles and other abnormalities that appear only after emptying, with repeated strain/defecation maneuvers recommended to maximize detection of pelvic floor dysfunction 1, 3, 4

The American College of Radiology guidelines do not mention specific post-procedure restrictions for diagnostic defecography, but standard barium elimination precautions apply, including increased fluid intake and monitoring for constipation from residual barium 1, 8
If surgical intervention follows, bowel management with stool softeners is recommended during recovery to prevent straining, with surgical approach selection depending on patient factors, including abdominal approaches with lower recurrence rates but higher morbidity, and perineal approaches suitable for elderly or high-risk patients but with higher recurrence rates 9