Anal Hypertonia Research Articles

Anogenital symptoms and lesions in a series of 20 patients infected with monkeypox virus.

Monkeypox virus (MPXV) has been spreading in many European countries, the USA and Canada since May 2022. General symptoms, skin and anoperineal lesions have been reported. Anal pain is often reported, but anal canal lesions have yet to be described in these patients. The aim of this study was to describe anoperineal lesions in patients infected with MPXV undergoing systematic margin and anal canal examination at a tertiary care centre in France. In this prospective descriptive study, systematic anal examination was performed in 20 patients diagnosed with MPXV infection at Bichat Hospital, Paris, France between 6 and 11 July 2022. Anal swabs were also obtained from all these patients for polymerase chain reaction testing for MPXV. All the patients were men that have sex with men (MSM). Sixteen patients had anal symptoms: 13 reported anal pain, and the other anal symptoms described were anal bleeding (n=12), pruritus (n=11), dyschezia (n=10), tenesmus (n=13), burning (n=3), swelling (n=9) and discharge of mucus (n=9). Proctological examination detected: (i) anal margin lesions in 14 patients (vesicles, n=8; pustules, n=6; ulceration, n=6); (ii) anal canal lesions in 16 patients (ulceration, n=13; ulcers, n=4; pustules, n=1), seven of whom presented anal hypertonia; and (iii) rectal lesions in 12 patients (congested rectum, n=6; erythema, n=10; ulcers, n=2; not seen in one case). the presence of mucus was noted in 10 patients and the presence of blood in six patients. This is the first study to describe anal canal lesions in patients infected with MPXV. Most of the observed lesions were ulceration, accounting for the pain reported.

Инкоботулотоксин А в детской колопроктологии. Первый опыт применения в России

In the last decade, botulinum toxin type A (BTA) has been used in children with colorectal diseases. There are no published papers on the topic in Russia. Objective. To investigate BTA effectiveness in children with different colorectal problems. Patients and methods. 9 patients from 1.7 to 14 years old (median age 3.5 years) were treated with the new method in the Speransky Children's Hospital (Moscow, Russia). The indications for treatment were various complaints (constipation, fecal pseudo-incontinence, painful defecation, obstructive defecation), anal hypertonia (spasm). We treated children in whom conservative therapy was ineffective. Incobotulinumtoxin A was administered under general anesthesia at a dose of 3–6 U/kg at 4 points along the circumference of the anal canal. Results. The effect of therapy was obtained in 7 out of 9 patients (77.8%). A good and excellent result was recorded in 4 patients (44.4%), mild – in 3 (33.3). There was no effect in two children with genetic pathology and Hirschsprung's disease with colostomy (22.2%). Conclusion. Circumferential chemodenervation with incobotulinumtoxin A of anal sphincters is an effective and safe method of treating children with defecation disorders resistant to routine conservative therapy, but further research is needed to develop patient selection, dose calculation and create guidelines injection technique and its frequency. Key words: dyssynergic defecation, painful defecation, hirschsprung, achalasia, incobotulinumtoxin A, children

Analgesic injection of botulinum toxin in anal fissures is efficient and can be performed safely in patients actively receiving chemotherapy.

Injection of botulinum toxin into the internal anal sphincter is a well-documented intervention to reduce anal hypertonia in the treatment of anal fissures. In patients receiving chemotherapy, painful anal conditions are frequent, secondary to change in bowel habits and reduced immunity. However, injection of botulinum toxin is often not offered due to fear of complications. In this retrospective longitudinal observational study, performed in a tertiary hospital setting, we analysed patient characteristics, outcome and complication rates of botulinum toxin injection in patients actively receiving chemotherapy. Twenty-six patients were treated with 20-50 IU botulinum toxin while actively receiving chemotherapy because of intractable pain and hypertonia. The fissure was located dorsally in 69% (n = 18) and ventrally in 19% (n = 5), while in 3 patients (12%), no fissure was documented. The majority of the patients (88%, n = 23) had complete (54%, n = 14) or partial (35%, n = 9) relief of pain. In three patients, additional anal pathology developed in the weeks following botulinum toxin injection: thrombosis of grade IV haemorrhoids, perianal haematoma and an intersphincteric abscess. Injection of botulinum toxin in the anal sphincters is a safe and effective analgesic option in patients with anal fissure while actively receiving chemotherapy.

Tonus anal : déterminant physiologique, évaluation clinique et paraclinique, caractéristique pathologique

The anal tone allows the maintenance of anorectal continence. Its regulation depends on spinal segmental mechanisms under supra-sacral control. A systematic review was performed using Medline database, according to PRISMA methodology, using following keywords anal tone; anal sphincter; anorectal function; reflex; digital rectal examination. Anal hypertonia is an increase in the muscle's resistance to passive stretching. Muscular hypotonia is a decrease in muscle tone. It is associated with a decrease in resistance to passive mobilization. It is not possible to quantify the prevalence of anal tone alterations in the general population and in specific pathological conditions (urinary disorders, neurogenic or non-neurogenic anorectal disorders). In case of hypotonia, most often due to a lower motor neuron lesion, fecal incontinence may occur. Hypertonia (anal sphincter overactivity) is not always due to perineal spasticity. Indeed, in the majority of the cases, the cause of this anal hypertonia in a neurologic context, can be secondary to an upper motor neuron disease due to spinal or encephalic lesion, leading to recto-anal dyssynergia, giving distal constipation. In another way, this anal hypertonia can be purely behavioral, with no direct pathological significance. The evaluation of anal tone is clinical with validated scores but whose sensitivity is not absolute, and instrumental with, on the one hand, the measurement of anal pressure in manometry and, on the other hand, electrophysiological testing which still require validation in this indication. Anal tone assessment is of interest in clinical practice because it gives diagnostic arguments for the neurological lesion and its level, in the presence of urinary or anorectal symptoms.

Anoplasty with skin tag flap for the treatment of chronic anal fissure.

to evaluate the long-term results of the correction of chronic anal fissures (CAF) in patients without anal hypertonia using the technique of anoplasty with skin tag flap. we conducted a prospective study of CAF patients refractory to conservative treatment without anal hypertonia, subjected to anoplasty with the use of anal plicoma to cover the bloody area. We confirmed the absence of anal hypertonia through rectal exam and electromanometry. We applied a visual pain questionnaire and the Cleveland Clinic fecal incontinence score before and after surgery. we followed 15 patients with chronic anal fissure for a mean period of 29 months (12-56). The mean age was 41 years (29-69) and the duration of symptoms ranged from six months to five years. Healing occurred between three and six weeks for 13 patients (86.7%). The other two patients underwent debridement and new anoplasty successfully. No plicoma necrosis or anal stenosis occurred in any patient. The anal incontinence score did not change after the procedure, and all patients reported reduced pain. After 12 months of follow-up, none of the patients presented recurrence or anal incontinence, and 93.3% (14/15) of the patients were very satisfied. fissurectomy and anoplasty with the use of sentinel plie is a safe technique that results in improvement in pain without change of fecal continence and with high satisfaction rates.

Role of Anorectal Manometry in Anal Fissure and Outcome of Tailored Lateral Sphincterotomy in Hypertensive Internal Anal Sphincter: A Modified Minimal Invasive Technique

AbstractBackground: CAF is a common benign anorectal problem that substantialy impairs the patient's life. Consequently, a rapid and effective solution is required.1Aim of Study: To do lateral internal sphincterotomy extending up to the upper end of the fissure (but not to the dentate line) in patients have CAF with hypertonic IAS to keep continence. In case of low RAP, V-Y plasty will be done.Patients and Methods: Our study was done on 34 patients with CAF divided into 2 groups, group 1 included 28 patients with hypertonic IAS underwent tailored LIS and group 2 included 6 patients with normotonic/ hypotonic IAS underwent V-Y plasty to keep continence from June 2017 till December 2017 in general surgery department ,Assiut university hospital.Results: In group 1 there is no incontinence or recurrence, complete healing of fissures occurred in 96.4%. Only one patient had unhealing fissures, postoperative complications include bruising occurred in 3.5% and minor sepsis of sphinc-terotomy wound in 3.5%, in group 2 there is minor sepsis of the flap in 16.6%.Conclusion: Our study was done on 34 patients with CAF. These patients were divided according to anomanometric study into 2 groups: - Group 1 included 28 patients with high RAP in whom tailored LIS was done by modified technique which is taiored equal to the length of the fissure which is minimally invasive with good healing rate and no recurrence or incontince postoperative and minor bruising and sepsis of the wound and significant reduction in postoperative RAP. - Group 2 included 6 patients with normotonic /hypotonic IAS in whom excison of fissures were done and the defect is closed by V-Y plasty with good healing rate and low postoperative sepsis.So tailored lateral internal sphincterotomy is the effective treatment of CAF with anal hypertonia, safe and not affect continence.

Topical Glyceryl Trinitrate Ointment for Pain Related to Anal Hypertonia After Stapled Hemorrhoidopexy

Postoperative pain after stapled hemorrhoidopexy is cause for considerable concern and may be related to contracture of continence muscles. We compared glyceryl trinitrate 0.4% ointment with lidocaine chlorohydrate 2.5% gel as topical therapy to relieve the pain of anorectal muscular spasm after stapled hemorrhoidopexy. This was a single-blind, parallel-group, randomized controlled trial. The study was conducted at a university teaching hospital in Rome, Italy. Patients with severe postoperative anal pain after stapled hemorrhoidopexy, clinical evidence of anal hypertonia, and elevated anal resting pressure on manometric assessment were enrolled. Patients treated for concomitant anorectal disease were excluded. Participants were randomly assigned to receive twice-daily, local topical application of glyceryl trinitrate or lidocaine for a total of 14 days. Pain intensity was measured on a visual analog scale at baseline and after 2, 7, and 14 days of therapy. Anal resting pressure was measured pre- and postoperatively and after 14 days of therapy. Of 480 patients undergoing stapled hemorrhoidopexy, 121 had severe postoperative pain (score >3) and underwent clinical examination; 45 patients (13 women, 28 men) had clinically evident anal hypertonia and underwent anorectal manometry; 41 patients had elevated anal resting pressure and entered the study. Mean pain scores were significantly lower with glyceryl trinitrate than with lidocaine on day 2 (2.5 ± 1.0 vs 4.0 ± 1.1, p < 0.0001); day 7 (1.4 vs 2.8, p < 0.0001); and day 14 (0.4 vs 1.4, p = 0.003). Anal resting pressure was significantly lower with glyceryl trinitrate than with lidocaine on day 14 (75.4 ± 7.4 mmHg vs 85.6 ± 7.9 mmHg, p < 0.0001). GTN-induced reduction in sphincter tone could not be evaluated during the initial period, when pain was most intense. Because anorectal manometry was performed only in patients with severe pain and clinical evidence of anal hypertonia, firm conclusions cannot be drawn as to frequency of hypertonia after SH. Bias may have been introduced because the surgical team could not be blinded. Topical 0.4% glyceryl trinitrate is effective in relieving pain and reducing anal resting pressure in patients with anal hypertonia after stapled hemorrhoidopexy.

The management of patients with primary chronic anal fissure: a position paper

Anal fissure is one of the most common and painful proctologic diseases. Its treatment has long been discussed and several different therapeutic options have been proposed. In the last decades, the understanding of its pathophysiology has led to a progressive reduction of invasive and potentially invalidating treatments in favor of conservative treatment based on anal sphincter muscle relaxation. Despite some systematic reviews and an American position statement, there is ongoing debate about the best treatment for anal fissure. This review is aimed at identifying the best treatment option drawing on evidence-based medicine and on the expert advice of 6 colorectal surgeons with extensive experience in this field in order to produce an Italian position statement for anal fissures. While there is little chance of a cure with conservative behavioral therapy, medical treatment with calcium channel blockers, diltiazem and nifepidine or glyceryl trinitrate, had a considerable success rate ranging from 50 to 90%. Use of 0.4% glyceryl trinitrate in standardized fashion seems to have the best results despite a higher percentage of headache, while the use of botulinum toxin had inconsistent results. Nonresponding patients should undergo lateral internal sphincterotomy. The risk of incontinence after this procedure seems to have been overemphasized in the past. Only a carefully selected group of patients, without anal hypertonia, could benefit from anoplasty.

Role of age, bowel function and parity on anorectocele pathogenesis according to cinedefecography and anal manometry evaluation

The study aimed to verify the role of parity, age and bowel function in the pathogenesis of anorectocele. A cross-sectional study was conducted regarding age, obstetrical history, Cleveland Clinic Constipation Score (CCCS), cinedefecography and anal manometry findings. Forty-five adult women complaining of obstructed defecation were evaluated; the median age was 46 years and median CCCS, 13. Fifteen patients were nulliparous and 23 multiparous (median parity 2). Eighteen had a history of episiotomy, fourteen delivered large babies and two had forceps-assisted delivery. Statistical analysis was performed using Spearman's correlation test and Fisher's exact test. Anal hypertonia was found in 14 (31.1%) patients, anal hypotonia in eight (17.8%), anismus in 13 (28.9%) and anorectoceles in 34 (75.6%) [median size 2.8 cm (0-6.4)]. There were no correlations between anorectocele and anal hypertonia (P = 0.7171), anismus (P = 0.4666), parity comparing nulliparous and multiparous patients (P = 1.000), episiotomy (P = 1.0000), forceps assistance (P = 1.0000), delivery of a large baby (P = 1.0000) anal resting pressure (P = 0.0883), anal voluntary pressure (P = 0.7327), parity (P = 0.4987) and age (P = 0.8603). There were correlations between anorectocele and the CCCS (P = 0.0082) and anal hypotonia (P = 0.0141). Anorectocele is not correlated with parity, age, episiotomy, delivery of a large baby and anismus. It was more frequent in patients with severe constipation and less common in patients with anal hypotonia.

Role of constipation and anal hypertonia in the pathogenesis of haemorrhoids.

The hypothesis that haemorrhoids result from chronic constipation was investigated by studying bowel habit, anal pressure profiles and anal compliance in 13 men and 10 women with prolapsing haemorrhoids, 12 women with severe constipation and 14 male and 11 female control subjects. Defaecation was less frequent in women than in men (P less than 0.01) but was independent of the presence of haemorrhoids. Patients with haemorrhoids and control subjects reported similar stool consistency and rarely admitted to straining. Severely constipated women complained of infrequent defaecation, straining at stool and hard motions, but none had prolapsing haemorrhoids. Haemorrhoids were associated with significantly longer anal high-pressure zones and significantly greater maximum resting pressures at all levels of anal distension (P less than 0.01), but minimum residual pressure during rectal distension and maximum squeeze pressure were not significantly different from control subjects. Maximum resting pressure was increased in patients of both sexes with haemorrhoids, but this reached statistical significance only in men (P less than 0.001). Constipated women had normal anal pressure profiles and maximum anal pressures. These data show that patients with haemorrhoids are not necessarily constipated but tend to have abnormal anal pressure profiles and anal compliance. Chronically constipated women do not necessarily have haemorrhoids but have normal anal pressure profiles and compliance. This casts doubt upon the hypothesis that haemorrhoids are caused by constipation.

Submucosal reconstructive hemorrhoidectomy (Parks' operation): a 20–year experience

Submucosal reconstructive hemorrhoidectomy has never been a popular operation due to its difficulty and duration, the amount of blood loss, and the risk of incontinence. The main indication for hemorrhoidectomy according to Parks is fourth-degree hemorrhoids with prolapse of the dentate line outside the anus and with simultaneous presence of external hemorrhoids. We report our experience in the treatment of hemorrhoids using submucosal reconstructive hemorrhoidectomy according to Parks. A total of 640 patients (381 men and 259 women) of median age 42 years (range, 18-81) were treated between 1983 and 2002; 80% of patients had fourth-degree, 19% third-degree and 1% second- degree hemorrhoids. All patients underwent rectosigmoidoscopic examination before surgery; patients over 35 years of age or with a suspected inflammatory or neoplastic disease underwent colonoscopy or barium enema. All patients underwent anorectal manometry before operation, to measure anal resting pressure, maximal squeeze and sphincter length, with the purpose of determining if an internal sphincterotomy was also necessary (in case of high anal resting tone). One-third of the patients also had an internal sphincterotomy to correct anal hypertonia. Postoperative bleeding occurred in 19 patients (2.9%), 0.9% requiring a reintervention. Severe pain was reported by 9 patients (1.4%); fecal impaction occurred in 3 cases (0.5%) and suture disruption in 2 patients (0.3%). In 74 patients (11.6%), bladder catheterization was needed due to urinary retention. Of 550 patients who had a minimum follow-up of 3 years and were sent a postal questionnaire, 374 patients responded, with a median 7.3-year follow- up; 176 patients (32%) were lost to follow-up. Eleven patients (2.9% of 374 cases) reported pain during defecation, 6 (1.6%) developed skin tags or recurrence, 3 (0.8%) reported gas incontinence, 2 (0.5%) developed anal fistula and 1 (0.3%) had anal stricture. Submucosal reconstructive hemorrhoidectomy according to Parks still represents a good choice for the treatment of high-degree hemorrhoids with prolapse of the dentate line outside the anus and external circumferential hemorrhoids.

Anorectal manometry in children with chronic functional constipation

The anorectal manometry is a very utilized and well recognized examination in children with chronic functional constipation. The major manometric findings in these children are: anal hypotonia, anal hypertonia, paradoxal contraction of the external anal sphincter, decreased ability of internal anal sphincter to relax during rectal distension and alterations in rectal contractility, sensibility and compliance. To evaluate the anal basal pressure and the relaxation reflex before and after standard treatment for a better understanding of the physiopathologic mechanisms involved in pediatric chronic functional constipation. Anorectal manometry was performed before treatment on 20 children with chronic functional constipation aged 4 to 12 years and the results were compared to those obtained after standard treatment, with a good outcome. There was a reduction in anal basal pressure after treatment, but no differences were detected between the anorectal manometries performed before and after treatment in terms of amplitude and duration of relaxation, residual pressure, latency time, or descent and ascent angle. We conclude that the anal basal pressure decreased in children recovering from chronic functional constipation, but the standard treatment did not provide all the conditions necessary for the relaxation reflex of constipated children to return to the values described in normal children.

Comparison of the effects of nitric oxide donors and calcium channel blockers on the intrinsic myogenic tone of sheep isolated internal anal sphincter

Chronic anal fissure is associated with considerable pain and anal hypertonia. Numerous clinical studies attest to the effectiveness of individual nitro-containing drugs and organic calcium channel blockers in this condition but there are few comparative studies. Isolated segments of sheep internal anal sphincter were prepared for isometric tension recording. The effect of various drugs on myogenic tone was examined in the absence or presence of sodium orthovanadate (SOV), an agent used to mimic anal hypertonia by increasing myogenic tone. All the drugs tested produced concentration-dependent inhibition of myogenic tone, with the maximum effect ranging from 66.4 per cent (verapamil) to 100 per cent (sodium nitroprusside). Sodium nitroprusside and diltiazem were the most potent, followed by glyceryl trinitrate (GTN), nifedipine and verapamil, which had similar potency, and finally nicorandil. The potency of GTN and diltiazem was reduced threefold in the presence of 1 mmol/l SOV. The combined effect of GTN and diltiazem was greater than the effect of either agent alone, even in the presence of 3 mmol/l SOV. Nitro-containing drugs and organic calcium channel blockers are potent inhibitors of anal sphincter myogenic tone that may be used in combination to treat chronic anal fissure.

Digital Rectal Examination of Sphincter Pressures in Chronic Anal Fissure Is Unreliable

Chronic anal fissure is said to be associated with internal sphincter hypertonia. However, an unknown proportion of fissures may be associated with normal or even low resting pressures and may subsequently be resistant to pharmacological treatments or at risk from surgical treatments, both of which aim to reduce sphincter hypertonia. This study investigated the ability of surgeons to detect low or normal pressure fissures by digital rectal examination. Patients with chronic anal fissure were assessed prospectively. The results of anal manometry performed on these patients were compared with digital rectal assessment of sphincter tone undertaken by a surgeon blinded to the manometry results. Forty consecutive patients (21 male) with chronic anal fissure were studied. Twenty-two (55 percent) had normal maximum resting pressure and a further 3 (8 percent) had low pressures on anal manometry. On clinical assessment, only five (13 percent) patients were evaluated as having no anal hypertonia. Clinical assessment of anal tone correctly identified 14 of 15 patients with high manometric maximum resting pressure (sensitivity, 93 percent), yet detected only 4 of 25 patients with normal or low pressures (specificity, 16 percent). The positive predictive value of clinical assessment of anal tone was 40 percent and the negative predictive value, 80 percent. The incidence of patients with chronic anal fissure without high manometric maximum resting pressure is higher than previously reported. The ability of surgeons to identify this group clinically was poor. It is reasonable to treat all patients primarily medically, and then selectively investigate by manometry those patients who fail medical therapy before considering lateral sphincterotomy.

Treatment of resistant anal fissure with advancement anoplasty.

The primary aim of this study was to assess the outcome of advancement anoplasty in the treatment of chronic anal fissure, resistant to conventional therapy. The secondary aim was to evaluate the anal resting pressure in these patients with resistant fissures. Over a five-year period eight patients (2 male, median age 55 years, range 20-74) with resistant anal fissure were referred from 6 centres. They had endured symptoms for a median of 8 years (range 2-20) and had undergone a median of 2 previous surgical procedures (range 1-3), including lateral sphincterotomy and anal dilatation. Anorectal physiological testing was performed on all patients who then underwent advancement anoplasty. The outcome was analysed retrospectively. Pre-operative anorectal physiological testing showed a significantly lowered median maximal anal resting pressure of 42 mm H2O (range 12-72 mm H2O, normal range > 60 mm), P=0.03. All patients underwent advancement anoplasty. At a median of seven months follow-up (range 2-22) seven of eight patients had healed their fissure and were asymptomatic. The median healing time was four months (range 2-6). Patients with chronic anal fissure, resistant to conventional therapy, may be successfully treated by advancement anoplasty. Healing time however, may be prolonged. In this series patients had a decreased anal resting pressure rather than anal hypertonia.

Acute colonic dilatation associated with a painful anal fissure

We report the case of an elderly woman who developed acute colon dilatation as a consequence of a painful fissure of the anus with severe hypertonia. After having excluded mechanical aetiology, a lateral internal sphincterotomy was performed under local anaesthesia. The procedure cured the anal pain and, by facilitating normal bowel function, allowed resolution of abdominal symptoms. The aetiology of acute colonic dilatation in this patient may be related to the painful anal fissure and hypertonia. In the elderly, the presence of simple anal diseases may predispose to the occurrence of life-threatening complications, such as acute colonic dilatation.

Biofeedback training for constipation in adults and children.

Forty-two patients complaining of constipation with abnormal anorectal motility were studied: 20 children and 6 adult females had a decreased rectoanal inhibitory reflex (RAIR) amplitude and 16 adult females had anal hypertonia and ultra slow waves (USW). Biofeedback training was used to condition the patients to relax the anal sphincter during the desire to defecate. After two to eight (mean, 4) training sessions, the authors observed simultaneously a normal RAIR amplitude and recovery from constipation for at least six months in 15 children and five females with decreased RAIR amplitude. Nine of the adult females with hypertonia and USW were able to suppress USW but did not recover from constipation. The data suggest that biofeedback training could be useful in some groups of constipated patients.