Endoanal Ultrasonographic Imaging of the Anorectal Region

  • Giulio Aniello Santoro
  • Sthela M. Murad-Regadas


Endoanal ultrasound imaging is the gold standard for visualization of anal sphincter complex. High resolution 3D ultrasonography has further enhanced our understanding of anal sphincter anatomy. The new technology has enabled the practitioner to investigate perianal abscesses, defecatory dysfunction, and other benign pathologies.


Perianal abscess Perianal fistula Anal sphincter Fecal incontinence 


  1. 1.
    Santoro GA, Wieczorek AP, Dietz HP, Mellgren A, Sultan AH, Shobeiri SA, et al. State of the art: an integrated approach to pelvic floor ultrasonography. Ultrasound Obstet Gynecol. 2011;37(4):381–96.CrossRefPubMedGoogle Scholar
  2. 2.
    Groenendijk AG, Birnie E, Boeckxstaens GE, Roovens JP, Bonsel GJ. Anorectal function testing and anal endosonography in the diagnostic work-up of patients with primary pelvic organ prolapse. Gynecol Obstet Investig. 2009;67(3):187–94.CrossRefGoogle Scholar
  3. 3.
    Groenendijk AG, Birnie E, de Blok S, Adriaanse AH, Ankum WM, Roovens JP, Bonsel GJ. Clinical-decision taking in primary pelvic organ prolapse; the effects of diagnostic tests on treatment selection in comparison with a consensus meeting. Int Urogynecol J. 2009;20(6):711–9.CrossRefGoogle Scholar
  4. 4.
    Abdool Z, Sultan AH, Thankar R. Ultrasound imaging of the anal sphincter complex: a review. Br J Radiol. 2012;85(1015):865–75.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Santoro GA, Fortling B. The advantages of volume rendering in three-dimensional endosonography of the anorectum. Dis Colon Rectum. 2007;50(3):359–68.CrossRefPubMedGoogle Scholar
  6. 6.
    Santoro GA, Di Falco G. Endoanal and endorectal ultrasonography: methodology and normal pelvic floor anatomy. In: Santoro GA, Wieczorek AP, Bartram C, editors. Pelvic floor disorders imaging and a multidisciplinary approach to management. Milan: Springer Verlag Italia; 2010. p. 91–102.Google Scholar
  7. 7.
    Santoro GA, Sultan AH. Pelvic floor anatomy and imaging. Semin Colon Rectal Surg. 2016;27(1):5–14.CrossRefGoogle Scholar
  8. 8.
    Williams AB, Cheetham MJ, Bartram CI, Halligan S, Kamm MA, Nicholls RJ, Kmiot WA. Gender differences in the longitudinal pressure profile of the anal canal related to anatomical structure as demonstrated on three-dimensional anal endosonography. Br J Surg. 2000;87(12):1674–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Regadas FS, Murad-Regadas SM, Lima DM, Silva FR, Barreto RG, Souza MH, Regadas Filho FS. Anal canal anatomy showed by three-dimensional anorectal ultrasonography. Surg Endosc. 2007;21(12):2207–11.CrossRefPubMedGoogle Scholar
  10. 10.
    Bollard RC, Gardiner A, Lindow S, Phillips K, Duthie GS. Normal female anal sphincter: difficulties in interpretation explained. Dis Colon Rectum. 2002;45(2):171–5.CrossRefPubMedGoogle Scholar
  11. 11.
    Gold DM, Bartram CI, Halligan S, Humphries KN, Kamm MA, Kmiot WA. Three-dimensional endoanal sonography in assessing anal canal injury. Br J Surg. 1999;86(3):365–70.CrossRefPubMedGoogle Scholar
  12. 12.
    Frudinger A, Halligan S, Bartram CI, Price AB, Kamm MA, Winter R. Female anal sphincter: age-related differences in asymptomatic volunteers with high-frequency endoanal US. Radiology. 2002;224(2):417–23.CrossRefPubMedGoogle Scholar
  13. 13.
    West RL, Felt-Bersma RJF, Hansen BE, Schouten WR, Kuipers EJ. Volume measurements of the anal sphincter complex in healthy controls and fecal-incontinent patients with a three-dimensional reconstruction of endoanal ultrasonography images. Dis Colon Rectum. 2005;48(3):540–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J. 2010;21(1):5–26.CrossRefPubMedGoogle Scholar
  15. 15.
    Santoro GA. Which method is best for imaging of anal sphincter defects? Dis Colon Rectum. 2012;55(6):625–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Santoro GA, Di Falco G. Endosonographic anatomy of the normal rectum. In: Santoro GA, Di Falco G, editors. Benign anorectal diseases. Diagnosis with endoanal and endorectal ultrasonography and new treatment options. Milan: Springer Italy; 2006 p. 55–60.Google Scholar
  17. 17.
    Macmillan AK, Merrie AE, Marshall RJ, Parry BR. The prevalence of fecal incontinence in community-dwelling adults: a systematic review of the literature. Dis Colon Rectum. 2004;47(8):1341–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Bliss DZ, Mellgren A, Whitehead WE, Chiarioni G, Emmanuel A, Santoro GA, et al. Assessment and conservative management of faecal incontinence and quality of life in adults. In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence. 5th International Consultation on Incontinence. Paris: ICUD-EAU; 2013. p. 1443–86.Google Scholar
  19. 19.
    Starck M, Bohe M, Valentin L. Results of endosonographic imaging of the anal sphincter 2–7 days after primary repair of third or fourth-degree obstetric sphincter tears. Ultrasound Obstet Gynecol. 2003;22(6):609–15.CrossRefPubMedGoogle Scholar
  20. 20.
    Norderval S, Dehli T, Vonen B. Three-dimensional endoanal ultrasonography: intraobserver and interobserver agreement using scoring systems for classification of anal sphincter defects. Ultrasound Obstet Gynecol. 2009;33(3):337–43.CrossRefPubMedGoogle Scholar
  21. 21.
    Voyvodic F, Rieger NA, Skinner S, Schloithe AC, Saccone GT, Sage MR, Wattchow DA. Endosonographic imaging of anal sphincter injury. Does the size of the tear correlate with the degree of dysfunction? Dis Colon Rectum. 2003;46(6):735–41.CrossRefPubMedGoogle Scholar
  22. 22.
    Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal sphincter disruption during vaginal delivery. N Engl J Med. 1993;329(26):1905–11.CrossRefPubMedGoogle Scholar
  23. 23.
    Oberwalder M, Connor J, Wexner SD. Meta-analysis to determine the incidence of obstetric anal sphincter damage. Br J Surg. 2003;90(11):1333–7.CrossRefPubMedGoogle Scholar
  24. 24.
    Oberwalder M, Dinnewitzer A, Baig MK, Thaler K, Cotman K, Nogueras JJ, et al. The association between late-onset fecal incontinence and obstetric anal sphincter defects. Arch Surg. 2004;139(4):429–32.CrossRefPubMedGoogle Scholar
  25. 25.
    Harvey MA, Pierce M, Alter JE, Chou Q, Diamond P, Epp A, et al. Society of obstetricians and gynaecologists of Canada. Obstetrical Anal Sphincter Injuries (OASIS): prevention, recognition, and repair. J Obstet Gynaecol Can. 2015;37(12):1131–48.CrossRefPubMedGoogle Scholar
  26. 26.
    Walsh KA, Grivell RM. Use of endoanal ultrasound for reducing the risk of complications related to anal sphincter injury after vaginal birth. Cochrane Datab Syst Rev. 2015;29(10):CD010826. doi: 10.1002/14651858.CD010826.pub2.
  27. 27.
    Fitzpatrick M, Cassidy M, Barassaud ML, Hehir MP, Hanly AM, O’Connell PR, O’Herlihy C. Does anal sphincter injury preclude subsequent vaginal delivery? Eur J Obstet Gynecol Reprod Biol. 2016;198:30–4.CrossRefPubMedGoogle Scholar
  28. 28.
    Oude Lohuis EJ, Everhardt E. Outcome of obstetric anal sphincter injuries in terms of persisting endoanal ultrasonographic defects and defecatory symptoms. Int J Gynaecol Obstet. 2014;126(1):70–3.CrossRefPubMedGoogle Scholar
  29. 29.
    Reid AJ, Beggs AD, Sultan AH, Roos AM, Thakar R. Outcome of repair of obstetric anal sphincter injuries after three years. Int J Gynaecol Obstet. 2014;127(1):47–50.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Royal College of Obstetricians and Gynecologists (RCOG). The management of third- and fourth- degree perineal tears (Green-top Guideline No. 29). 3rd ed. London UK: RCOG Press; 2015; p. 1–19.Google Scholar
  31. 31.
    Laine K, Skjeldestad FE, Sanda B, Horne H, Spydslaug A, Staff AC. Prevalence and risk factors for anal incontinence after obstetric anal sphincter rupture. Acta Obstet Gynecol Scand. 2011;90(4):319–24.CrossRefPubMedGoogle Scholar
  32. 32.
    Norderval S, Røssaak K, Markskog A, Vonen B. Incontinence after primary repair of obstetric anal sphincter tears is related to relative length of reconstructed external sphincter: a case-control study. Ultrasound Obstet Gynecol. 2012;40(2):207–14.CrossRefPubMedGoogle Scholar
  33. 33.
    Soerensen MM, Pedersen BG, Santoro GA, Buntzen S, Bek K, Laurberg S. Long-term function and morphology of the anal sphincters and the pelvic floor after primary repair of obstetric anal sphincter injury. Color Dis. 2014;16(10):O347–55.CrossRefGoogle Scholar
  34. 34.
    Karmarkar R, Bhide A, Digesu A, Khullar V, Fernando R. Mode of delivery after obstetric anal sphincter injury. Eur J Obstet Gynecol Reprod Biol. 2015;194:7–10.CrossRefPubMedGoogle Scholar
  35. 35.
    Pucciani F, Raggioli M, Gattai R. Rehabilitation of fecal incontinence: what is the influence of anal sphincter lesions? Tech Coloproctol. 2013;17(3):299–306.CrossRefPubMedGoogle Scholar
  36. 36.
    Allgayer H, Ignee A, Zipse S, Crispin A, Dietrich CF. Endorectal ultrasound and real-time elastography in patients with fecal incontinence following anorectal surgery: a prospective comparison evaluating short- and long-term outcomes in irradiated and non-irradiated patients. Z Gastroenterol. 2012;50(12):1281–6.CrossRefPubMedGoogle Scholar
  37. 37.
    Albuquerque A, Macedo G. Clinical severity of fecal incontinence after anorectal surgery and its relationship with endoanal ultrasound features. Int J Color Dis. 2016;31(7):1395–6.CrossRefGoogle Scholar
  38. 38.
    de la Portilla F, Vega J, Rada R, Segovia-Gonzáles MM, Cisneros N, Maldonado VH, Espinosa E. Evaluation by three-dimensional anal endosonography of injectable silicone biomaterial (PTQ) implants to treat fecal incontinence: long-term localization and relation with the deterioration of the continence. Tech Coloproctol. 2009;13(3):195–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Ratto C, Buntzen S, Aigner F, Altomare DF, Heydari A, Donisi L, et al. Multicentre observational study of the Gatekeepe for faecal incontinence. Br J Surg. 2016;103(3):290–9.CrossRefPubMedGoogle Scholar
  40. 40.
    Lienemann A, Anthuber C, Baron A, Kohz P, Reiser M. Dynamic MR colpocystorectography assessing pelvic floor descent. Eur Radiol. 1997;7(8):1309–17.CrossRefPubMedGoogle Scholar
  41. 41.
    Kaufman HS, Buller JL, Thompson JR, Pannu HK, DeMeester SL, Genadry RR, et al. Dynamic pelvic magnetic resonance imaging and cystocolpoproctography alter surgical management of pelvic floor disorders. Dis Colon Rectum. 2001;44(11):1575–83.CrossRefPubMedGoogle Scholar
  42. 42.
    Dvorkin LS, Hetzer F, Scott SM, Williams NS, Gedroyc W, Lunniss PJ. Open-magnet MR defaecography compared with evacuation proctography in the diagnosis and management of patients with rectal intussusception. Color Dis. 2004;6(1):45–53.CrossRefGoogle Scholar
  43. 43.
    Barthet M, Portier F, Heyries L, Orsoni P, Bouvier M, Houtin D, et al. Dynamic anal endosonography may challenge defecography for assessing dynamic anorectal disorders: Results of a prospective pilot study. Endoscopy. 2000;32(4):300–5.CrossRefPubMedGoogle Scholar
  44. 44.
    Van Outryve SM, Van Outryve MJ, De Winter BY, Pelckmans PA. Is anorectal endosonography valuable in dyschesia? Gut. 2002;51(5):695–700.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Beer-Gabel M, Teshler M, Schechtman E, Zbar AP. Dynamic transperineal ultrasound vs. defecography in patients with evacuatory difficulty: a pilot study. Int J Color Dis. 2004;19(1):60–7.CrossRefGoogle Scholar
  46. 46.
    Dietz HP, Steensma AB. Posterior compartment prolapse on two-dimensional and three-dimensional pelvic floor ultrasound: the distinction between true rectocele, perineal hypermobility and enterocele. Ultrasound Obstet Gynecol. 2005;26(1):73–7.CrossRefPubMedGoogle Scholar
  47. 47.
    Murad-Regadas SM, Regadas FS, Rodrigues LV, Souza MH, Lima DM, Silva FRS, Filho FS. A novel procedure to assess anismus using three-dimensional dynamic ultrasonography. Color Dis. 2007;9(2):159–65.CrossRefGoogle Scholar
  48. 48.
    Murad-Regadas SM, Regadas FS, Rodrigues LV, Silva FR, Soares FA, Escalante RD. A novel three-dimensional dynamic anorectal ultrasonography technique (echodefecography) to assess obstructed defecation, a comparison with defecography. Surg Endosc. 2008;22(4):974–9.CrossRefPubMedGoogle Scholar
  49. 49.
    Regadas FS, Haas EM, Abbas MA, Marcio Jorge J, Habr-Gama A, Sands D, et al. Prospective multicenter trial comparing echodefecography with defecography in the assessment of anorectal dysfunctions in patients with obstructed defecation. Dis Colon Rectum. 2011;54(6):686–92.CrossRefPubMedGoogle Scholar
  50. 50.
    Murad-Regadas SM, dos Santos SG, Regadas FS, Rodrigues LV, Buchen G, et al. A novel three-dimensional dynamic anorectal ultrasonography technique for the assessment of perineal descent, compared with defaecography. Color Dis. 2012;14(6):740–7.CrossRefGoogle Scholar
  51. 51.
    Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg. 1976;63(1):61–2.CrossRefGoogle Scholar
  52. 52.
    Buchanan GN, Williams AB, Bartram CI, Halligan S, Nicholls RJ, Cohen RJ. Potential clinical implications of direction of a trans-sphincteric anal fistula track. Br J Surg. 2003;90(10):1250–5.CrossRefPubMedGoogle Scholar
  53. 53.
    Garcés-Albir M, García-Botello SA, Esclapez-Valero P, Sanahuja-Santafé A, Raga-Vázquez J, Espi-Macías A, Ortega-Serrano J. Quantifying the extent of fistulotomy. How much sphincter can we safely divide? A three-dimensional endosonographic study. Int J Color Dis. 2012;27(8):1109–16.CrossRefGoogle Scholar
  54. 54.
    Law PJ, Talbot RW, Bartram CI, Northover JMA. Anal endosonography in the evaluation of perianal sepsis and fistula in ano. Br J Surg. 1989;76(7):752–5.CrossRefPubMedGoogle Scholar
  55. 55.
    Poen AC, Felt-Bersma RJF, Eijsbouts QA, Cuesta MA, Neuwissen SG. Hydrogen peroxide-enhanced transanal ultrasound in the assessment of fistula-in-ano. Dis Colon Rectum. 1998;41(9):1147–52.CrossRefPubMedGoogle Scholar
  56. 56.
    Deen KI, Williams JG, Hutchinson R, Keighley MR, Kumar D. Fistulas in ano: endoanal ultrasonographic assessment assists decision making for surgery. Gut. 1994;35(3):391–4.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Cho DY. Endosonographic criteria for an internal opening of fistola-in-ano. Dis Colon Rectum. 1999;42(4):515–8.CrossRefPubMedGoogle Scholar
  58. 58.
    Santoro GA, Ratto C. Accuracy and reliability of endoanal ultrasonography in the evaluation of perianal abscesses and fistula-in-ano. In: Santoro GA, Di Falco G, editors. Benign anorectal diseases. Milan: Springer-Verlag Italia; 2006. p. 141–57.CrossRefGoogle Scholar
  59. 59.
    West RL, Dwarkasing S, Felt-Bersma RJ, Schouten WR, Hop WC, Hussain SM, Kuipers EJ. Hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging in evaluating perianal fistulas: agreement and patient preference. Eur J Gastroenterol Hepat. 2004;16(12):1319–24.CrossRefGoogle Scholar
  60. 60.
    Ratto C, Grillo E, Parello A, Costamagna G, Doglietto GB. Endoanal ultrasound-guided surgery for anal fistula. Endoscopy. 2005;37(8):1–7.CrossRefGoogle Scholar
  61. 61.
    Santoro GA, Ratto C, Di Falco G. Three-dimensional reconstructions improve the accuracy of endoanal ultrasonography in the identification of internal openings of anal fistulas. Color Dis. 2004;6(Suppl 2):214.Google Scholar
  62. 62.
    Buchanan GN, Halligan S, Bartram CI, Williams AB, Tarroni D, Cohen CR. Clinical examination, endosonographym and MR imaging in preoperative assessment of fistula in ano: comparison with outcome-based reference standard. Radiology. 2004;233(3):674–81.CrossRefPubMedGoogle Scholar
  63. 63.
    Siddiqui MR, Ashrafian H, Tozer P, Daulatzai N, Burling D, Hart A, et al. A diagnostic accuracy meta-analysis of endoanal ultrasound and MRI for perianal fistula assessment. Dis Colon Rectum. 2012;55(5):576–85.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Giulio Aniello Santoro
    • 1
  • Sthela M. Murad-Regadas
    • 2
    • 3
    • 4
  1. 1.Pelvic Floor Unit, Department of SurgeryTreviso Regional HospitalTrevisoItaly
  2. 2.Department of SurgeryMedical School of Federal University of Ceara, Rua Prof. Costa Mendes, 1608-3° andar - Rodolfo Teófilo - CEP, 60416-200FortalezaBrazil
  3. 3.Unit of Pelvic Floor and Anorectal PhysiologyClinical Hospital, Medical School of Federal University of CearáFortalezaBrazil
  4. 4.Unit of Pelvic Floor of Sao Carlos HospitalFortalezaBrazil

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