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Letters |
Academic Medical Center
Amsterdam, The Netherlands
We thank Dr. Karasick for his interest in our article [1]. He comments on several aspects of our reproducibility study concerning defecography in fecal-incontinent patients. We agree with Dr. Karasick that a major indication for performing defecography is to diagnose rectal intussusception. Because our study was performed as part of a larger diagnostic cohort study for which the primary focus was evaluating the effect of biofeedback in fecal-incontinent patients, we could not include patients with an external rectal prolapse (grade 3 intussusception) given that they are not treated with biofeedback but instead immediately undergo surgery. Furthermore, an external rectal prolapse is not part of a diagnostic problem in fecal-incontinent patients.
The relationship between fecal incontinence and rectocele as well as enterocele can be described as follows. Fecal incontinence is often a multifactorial disorder [2]. A large number of patients have concomitant symptoms of pelvic outlet obstruction [3]. Most patients with a rectocele have coexisting findings such as intussusception [4]. Not rarely, an enterocele accompanies a rectal intussusception or rectal prolapse [3]. Both rectocele and enterocele are signs of pelvic laxity or pelvic relaxation. A low compliance is a common finding in these cases that may result in fecal incontinence [5].
Dr. Karasick made an appropriate remark concerning the tenuous radiographic criteria to diagnose anismus. We had adopted the diagnostic criteria as reported by Halligan et al. [6, 7]. The difficulty in applying some criteria was already recognized by our study group as documented in the Discussion section, last paragraph, Anismus subheading. We assume that the absence of explicit diagnostic criteria might have influenced the intraobserver as well as the interobserver reliability of anismus diagnoses.
The suggestion from Dr. Karasick to use full-thickness intussusception as part of our grading system for intussusception was not supported by our research group. The purpose of the grading system for intussusception, which is shown in Figure 3, is to distinguish between differences in grading and not to assess whether the finding is normal or not. Furthermore, we prefer to use generally accepted terminology for our grading systems.
The primary aim of our study was to determine the interobserver agreement of defecography in diagnosing enterocele, anterior rectoceles, intussusception, and anismus in fecal-incontinent patients. As we stated in the introduction, this article is the first reproducibility study in a large group of patients with fecal incontinence resulting from different causes.
Our study might be of interest to the general radiologist for various reasons: First, for diagnosing intussusceptions, a highly experienced observer is needed. Second, level of observer experience seems to play a role in diagnosing anterior rectoceles and its grading and in diagnosing intussusception. Because intussusceptions and rectoceles may require surgical treatment, adequate assessment by experienced radiologists is needed. Third, to diagnose anismus, explicit diagnostic criteria are needed to make accurate assessment possible.
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