Anal Sphincter Integrity Research Articles

Automatic anal sphincter integrity detection from ultrasound images via convolutional neural networks.

The anal sphincter complex comprises the anal sphincter and the U-shaped deep and superficial puborectalis muscle. As an important supporting structure of the posterior pelvic floor, together with its surrounding tissues and muscles, the anal sphincter complex maintains the normal physiological functions of defecation and continence. The plane required for diagnosing anal sphincter injury and the diagnosis of anal sphincter integrity through pelvic floor ultrasound are highly dependent on sonographers' experience. We developed a deep learning (DL) tool for the automatic diagnosis of anal sphincter integrity via pelvic floor ultrasound. A 2D detection network was trained to detect the bounding box of the anal sphincter. The pelvic floor ultrasound image and its corresponding oval mask were input into a 2D classification network to determine the integrity of the anal sphincter. The average precision (AP) and intersection over union (IoU) were used to evaluate the performance of anal sphincter detection. Receiver operating characteristic (ROC) analysis was used to evaluate the performance of the classification model. The Pearson correlation coefficients (r values) of the topmost and bottommost layers detected by the CNN and sonographers were 0.932 and 0.978, respectively. The best DL model yielded the highest area under the curve (AUC) of 0.808 (95% CI: 0.698-0.921) in the test cohort. The results from the CNN agreed well with the diagnostic results of experienced sonographers. We proposed, for the first time, a CNN to obtain the plane required for diagnosing anal sphincter injury on the basis of pelvic floor ultrasound and for preliminarily diagnosing anal sphincter injury.

Comparison of diagnostic criteria for significant anal sphincter defects between endoanal and transperineal ultrasound.

To evaluate the agreement between three-dimensional endoanal ultrasound (EAUS) and four-dimensional transperineal ultrasound (TPUS) in measuring anal sphincter defect angle. This was a secondary analysis of the PERINEAL study, which evaluated the effect of perineal wound infection on anal sphincter integrity. Women were reviewed once a week, until their perineal wound had healed or for up to a maximum of 16 weeks. At each visit, both EAUS and TPUS (the latter at rest and on maximum pelvic floor muscle contraction (PFMC)) were performed to evaluate the presence of external (EAS) and internal(IAS) anal sphincter defect and measure the defect size. The largest angle size of a defect at the same sphincter level was analyzed. A defect was deemed significant if it was > 30°. Kappa coefficient (κ), intraclass correlation coefficient and standard error of measurement (SEM) were calculated, using EAUS as the reference standard. In 73 women scanned at weekly intervals, a total of 250 EAUS and 250 TPUS scans were performed. An EAS defect was found in 55 (22.0%) EAUS images and 47 (18.8%) TPUS images. An IAS defect was found in 26 (10.4%) images on both modalities. There was excellent agreement (κ = 0.87) between TPUS and EAUS in diagnosing the presence of an EAS defect and perfect agreement (κ = 1.00) in diagnosing the presence of an IAS defect. TPUS performed at rest had poor and moderate agreement with EAUS in measuring EAS and IAS defect size, respectively, with respective SEMs of ± 16.1° and± 27.9°. TPUS performed during maximum PFMC had poor and moderate agreement with EAUS in measuring EAS and IAS defect size, respectively, with respective SEMs of ± 16.5° and± 26.4°. Based on the SEMs, if the diagnostic cut-off of 30° for defect size on TPUS was used, an incorrect diagnosis of significant EAS defect could occur in approximately 9-36% of women and an incorrect diagnosis of a significant IAS defect could occur in approximately 4-15% of women, using EAUS as the reference. This is the first study to compare directly anal sphincter defect angle measurements obtained on EAUS and TPUS. A cut-off angle of 30° should not be used for the diagnosis of a significant residual anal sphincter defect during TPUS examination. Further research is required to determine the optimal defect cut-off angle for TPUS. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Analysis of the efficacy of biofeedback for faecal incontinence after surgery for anorectal malformation

Objective To explore the therapeutic effects of biofeedback in the treatment of faecal incontinence (FI) after surgery for anorectal malformation (ARM). Methods Clinical data were collected from paediatric patients for postoperative biofeedback due to FI caused by ARM between May 2017 and November 2021. The data included the duration of symptoms, the integrity of the anal sphincter, anorectal manometry parameters, and FI scores. These patients were divided into the low ARM group (group A) and the high ARM group (group B). Results A total of 45 paediatric patients were enrolled in the study. There were 28 cases in group A and 17 cases in group B. The differences in age, gender, and body weight were not statistically significant between the two groups (p > 0.05). The differences in the clinical indicators were also not statistically significant between the two groups at the time of the initial evaluation. The duration of symptoms was 2.21 ± 0.71 years and 4.14 ± 1.89 years in groups A and B. There were 16 cases with an intact anal sphincter in group A and only two cases with an intact anal sphincter in group B. This difference was statistically significant between the two groups (p < .05). The anal resting pressure, initial sensitivity threshold, defaecation sensitivity threshold, defaecation urge threshold, and FI scores were significantly improved in both groups post-treatment compared to pre-treatment (p < .001). Strong impulses improved significantly in group A, while strong impulses did not improve significantly in group B. The multivariate logistic regression analysis with these variables further showed that symptom duration and anal sphincter integrity were the main factors influencing the therapeutic effects of biofeedback. Conclusion Biofeedback plays a positive role in the treatment of FI in paediatric patients following surgery for ARM. Symptom duration and anal sphincter integrity were found to be the main factors influencing the therapeutic effect of biofeedback.

Is there a role for transperineal ultrasound imaging of the anal sphincter immediately after primary repair of third degree tears?

ObjectiveWhen obstetric anal sphincter injuries are identified, it is crucial that the defects are repaired appropriately to achieve a better outcome. Although the presence of an intact anal sphincter is not the sole mechanism for maintaining continence, and not all women with an anal sphincter defect are symptomatic, there is an association between sphincter defects and anal incontinence. Our aim was to evaluate whether transperineal ultrasound (TPUS) is useful in assessing anal sphincter integrity immediately following primary repair of obstetric anal sphincter injuries (OASIs). Study DesignThis is a prospective observational study of women who sustained OASIs during their first vaginal delivery. Three dimensional (3D) TPUS was performed immediately after repair of OASIs to identify anal sphincter defects. A repeat TPUS was performed 12 weeks following repair. Results21 women sustained OASIs of whom 20 (95%) attended follow up. Eight (40%) had a grade 3a tear and 12 (60%) a 3b tear.8/20 (40%) women had residual external anal sphincter (EAS) defects identified by TPUS immediately after repair. Of these eight defects, six (75%) persisted at 12 weeks postpartum. No new defects were seen at follow up among the twelve women in whom no defect was seen immediately following the repair.Six residual EAS defects were found at 12 weeks postpartum. An EAS defect at 12 weeks postpartum was associated with anal incontinence (p = 0.04). Women with 3b tears were more likely to have anal incontinence (AI) and residual sonographic EAS defects when compared with 3a tears but this was not statistically significant. ConclusionsWomen who had no TPUS defect detected immediately following primary repair of OASIs, remained as such at 12 weeks postpartum. Of those in whom a defect was seen immediately after repair, it persisted in 75% of cases at 12 weeks. We believe that the value of TPUS immediately after repair appears to be limited and would need to be defined if it were to be considered for routine practice. Further research on its role immediately after repair of major tears (Grade 3C/4) is needed. In addition, performing ultrasound would require widespread training of obstetricians to develop expertise. This highlights the importance of adequate training of obstetricians in OASI repair.

Endoscopic Radiofrequency Ablation of Fistula in Ano (E-RaFisTura) in the Era of Surgical Innovation. A Serial Prospective Evaluation of 10 Patients

Background: Fistula in-ano is an abnormal chronic infected tunnel (tract) between the rectum or the anal canal and perianal skin usually, with granulation tissue which connecting a primary orifice (internal) to a secondary one (external). This morbid antity represents a dilemma for both, patients and surgeon-proctologists because of postoperative issues occurrence such as fecal incontinence. The surgical management of this infectious condition has emerged nowadays, by emphasing new surgical techniques that preserve anal sphincter's integrity and functional. Over the last decade, numerous techniques sparing anal sphinters have gained popularity such as endoscopic approach (VAAFT), Laser, fibrin glue, transanal advancement flap repair [1,6]. In the same perspective,we are presenting in this paper, our preliminary outcomes of a combination of endoscopic approach (VAAFT) with Radifrequency Ablation of the fistula's tract that we nicknamed with the acronym of E-RaFisTura). Methods: We enrolled 10 males patients with anal fistula, age groupe 50-70 years, without any comorbidity in the term of diabetes mellitus, bowel inflammatory disease. Preoperatively each of them underwent a digital rectal examination, pelvic MRI, colonoscopy to rule out any concomitant abscess, Crohn's disease. Fleet enema, subcutaneus lower molecular weight heparin as well as intravenous broad spectrum antibiotic were administered an hour prior the surgical procedure. All patients were shifted to endoscopic surgical treatment of anal fistula (VAAFT) by using the fistuloscope of Piercarlo Meinero combined to the device of Fistura (Radiofrequency Ablation) with its probe 6-7 F (Figure 1 a,b,c). Then we visualized the fistula's tract and we seal it with radiofrequency thermocoagulation without damaging the anal sphincters by closing the internal opening with a suture node (Vicryl Rapid 3-0). Taxinomically, 2 patients had intersphincteric fistula, 3 transphincteric and the 5 others had submucosal anal fistula. Outcomes: We are inthe third month of follow up, none of the aboved mentioned patients has presented any postoperative issue excepting some local discomfort in immediate postoperative day, relieved with voltaren. Furthermore, the orificial wound healing is successful. Conclusion: Focused on our preliminary results, despite the small volume of patients, this combination of endoscopic and radiofrequency ablation can be regarded with optimism in selected patients. We will perform a powerful prospective study with a huge sample to have more accurate opinion. Bioethics Considerations: All enrolled patients had given their written consent prior. Furthermore,this surgical trial was approved by the Ethical commitee of Our Clinic.

Effect of a subsequent pregnancy on anal sphincter integrity and function after obstetric anal sphincter injury (OASI)

Introduction and hypothesisEndoanal ultrasound (EAUS) and anal manometry are used in the assessment women with a history of obstetric anal sphincter injury (OASI), both postpartum and in a subsequent pregnancy, to aid counselling regarding mode of delivery (MOD).MethodsA prospective observational study between 2012 to 2020 was completed. Women were reviewed 3 months postpartum following OASI and in the second half of a subsequent pregnancy. Anorectal symptoms were measured using the validated St Mark’s Incontinence Score (SMIS: asymptomatic to mild symptoms = ≤ 4). Anal manometry (incremental maximum squeeze pressure [iMSP: normal = > 20 mmHg]) and EAUS (abnormal = sphincter defect > 1 h in size) were performed.ResultsOne hundred forty-six women were identified and 67.8% had an anal sphincter defect ≤ 1 h in size postnatally. In those with a defect ≤ 1 h, postpartum mean iMSP and SMIS significantly improved in a subsequent pregnancy (p = 0.04 and p = 0.01, respectively). In women with a defect > 1 h, there was no significant difference between the mean iMSP or SMIS score postnatally compared to a subsequent pregnancy. At both time points, significantly more women had an anal sphincter defect ≤ 1 h and SMIS of ≤ 4 (p = 0.001 and p < 0.001 respectively) compared to those with a defect < 1 h. In addition, significantly more women had an anal sphincter defect ≤ 1 h and iMSP ≥ 20 mmHg (p < 0.001). Overall, out of the 146 women included in this study, 76 (52.1%) with a defect ≤ 1 h also had an iMSP ≥ 20 mmHg and SMIS ≤ 4 at 3 months postpartum.ConclusionsWomen who remain asymptomatic with normal anal manometry and no abnormal sphincter defects on EAUS postnatally do not need to have these investigations repeated in a subsequent pregnancy and can be recommended to have a vaginal delivery. If our protocol was modified, over half of the women in this study could have had their MOD recommendation made in the postnatal period alone.

Outcome of anal symptoms and anorectal function following two obstetric anal sphincter injuries (OASIS)\u2014a nested case-controlled study

Introduction and hypothesisObstetric anal sphincter injury (OASI) is a significant risk factor for developing anal incontinence. It can therefore be hypothesised that recurrent OASI in a subsequent delivery may predispose women to further anal sphincter dysfunction.MethodsA nested case-controlled study based on data collected prospectively between 2006 and 2019. Women matched for age and ethnicity, with a history of one OASI and no sphincter damage in a subsequent delivery (control) were compared to women sustaining a second OASI. Assessment was carried out using the St Mark’s score (SMIS), anorectal manometry and endoanal ultrasound scan (findings quantified using the modified Starck score).ResultsEighty-four women were included and equally distributed between the two groups, who were followed up 12 weeks postnatally. No difference in SMIS scores was found. Maximum resting pressure (MRP, mmHg) and maximum squeeze pressure (MSP, mmHg) were significantly reduced in the study group. Median (IQR) MRP in the study group was 40.0 (31.3–54.0) versus 46.0 (39.3–61.5) in the control group (p = 0.030). Median (IQR) MSP was 73.0 (58.3–93.5) in the study group versus 92.5 (70.5–110.8) (p = 0.006) in the control group. A significant difference (p = 0.002) was found in the modified Starck score between the study group (median 0.0 [IQR 0.0–6.0]) and control group (median 0.0 [IQR 0.0–0.0]).ConclusionsWe have demonstrated that women with recurrent OASI do not have significant anorectal symptoms compared to those with one OASI 12 weeks after delivery, but worse anal sphincter function and integrity. Therefore, on long-term follow-up, symptoms may possibly develop. This information will be useful when counselling women in a subsequent pregnancy.

Role of Endoanal Ultrasonography in Grading Anal Sphincter Integrity in Rectal Prolapse and in Predicting Improvement in the Continence State After Surgical Treatment.

Rectal prolapse can be associated with fecal incontinence (FI) that may not completely resolve after surgical treatment. We aimed to examine the utility of endoanal ultrasonography (EAUS) in identifying the pattern of anal sphincter injury in rectal prolapse and in predicting the improvement in continence state after surgical treatment. Records of patients of rectal prolapse who underwent surgical treatment and were evaluated with EAUS before surgery were screened. According to the degree of anal sphincter injury preoperative EAUS, 4 grades of anal sphincter injury were recognized (0 to III). The preoperative patient characteristics and outcome of surgery in each group were compared. Fifty-nine patients (33 male), mean age 36.2 years, were included in the study. Forty-four (74.5%) patients complained of FI preoperatively. There were 12 (20.3%) patients with grade 0 injury, 29 (49.1%) with grade I, 7 (11.8%) with grade II, and 11 (18.6%) with grade III. Patients with grade III presented more with external rectal prolapse had a significantly longer duration of symptoms and had undergone previous surgery for rectal prolapse significantly more than the patients of the other 3 grades. Patients with grade II and grade III anal sphincter injury had significantly higher incontinence scores and lower anal pressures than grade 0 and grade I patients. Preoperative EAUS is a useful tool for the assessment of anal sphincter injury in patients with rectal prolapse and for predicting improvement in FI after surgical treatment as higher grades of sphincter injury were associated with less improvement in continence than lower grades.

Dynamic 2-dimensional transperineal ultrasound evaluation in labor room as a screening tool for anal sphincter injuries and anal incontinence in primiparous women

Early repair of obstetric anal sphincter injuries is crucial in the prevention of anal incontinence, but the diagnostic accuracy of the clinical examination after delivery is poor. Endoanal ultrasound imaging is now regarded as the gold standard for diagnosing anal sphincter injuries, and it improves the diagnosis of these lacerations. Four-dimensional transperineal ultrasound imaging has been proposed as an effective and less invasive alternative to endoanal ultrasound imaging in the diagnosis of anal sphincter injuries. The purpose of this study was to evaluate the feasibility and accuracy of the assessment of anal sphincter contraction by dynamic 2-dimensional transperineal ultrasound imaging immediately after delivery and its correlation with anal incontinence at the 4-month follow-up evaluation. A nonconsecutive series of nulliparous women with low-risk singleton term pregnancies were recruited in the labor room after vaginal delivery for the purpose of this study from January 2017 to July 2017. All enrolled patients had a clinical examination of the perineum by the caregiver that was repeated by an experienced research fellow. For each patient, a further dynamic 2-dimensional transperineal ultrasound imaging were carried out. Before the perineal repair, the women were asked to contract the anal sphincter during 2-dimensional transperineal ultrasound imaging; they were divided in 2 groups according to the sonographic findings: women with sonographic evidence of anal sphincter contraction (group A) and women with no evidence of contraction at ultrasound imaging (group B). A follow-up examination of anal sphincter integrity with 4-dimensional transperineal ultrasound imaging was carried out 4 months after delivery. At this time, the levator ani integrity was evaluated with the use of 4-dimensional transperineal ultrasound imaging, as previously described. Over the study period 69 women were enrolled. In 55 women (80%), there was evidence of proper anal sphincter contraction (group A); in 14 cases (20%), it was not possible to identify anal sphincter contraction with dynamic 2-dimensional transperineal ultrasound imaging (group B). Obstetric anal sphincter injuries that were detected through clinical examination were significantly more frequent in group B than in group A (13/14 [93%] vs 7/55 [12%]; P<.001). At the 4-month postpartum follow up, the previously recognized obstetric anal sphincter injuries were found to be repaired correctly; a third-degree perineal tear that had not been reported previously was diagnosed by 4-dimensional transperineal ultrasound imaging . Anal incontinence was reported in 8 of 69 patients (11%); it was more frequent in group B when compared with group A (4/14 [29%] vs 4/55 [7%]; P=.047). Dynamic 2-dimensional transperineal ultrasound imaging is a feasible technique and a useful supporting tool for the assessment of anal sphincter integrity in the labor room before suturing. Anal incontinence at the 4-month follow-up evaluation is more frequent among women with no evidence of anal sphincter contraction at dynamic 2-dimensional transperineal ultrasound imaging after delivery.

The relationship between residual sphincter damage after primary repair, faecal incontinence, and anal sphincter function in primiparous women with an obstetric anal sphincter injury.

Anal sphincter injury has been identified as a primary cause of post-partum fecal incontinence in women with obstetric anal sphincter injury. However, women without obstetric anal sphincter injury may also develop fecal incontinence. The aim is to determine the relationship between fecal incontinence severity; and i) residual anal sphincter injury, quantified by the Starck score, and ii) anal sphincter tone. Consecutive case series of prospectively collected data set in a Pelvic Floor Unit within a tertiary teaching hospital in Australia. Population 181 primiparous women with Sultan classification Grade 3 and 4 sphincter injuries. Sultan classification, anal manometry, pudendal nerve terminal motor latency, St Mark's fecal incontinence score, and Starck ultrasound score. 45% of women reported some degree of fecal incontinence. One third of women with normal external sphincter tone were incontinent. Those with higher Starck score had higher St Mark's scores. A higher Sultan classification correlated with more severe incontinence regardless if the repair was complete. Forceps delivery had a twofold risk of incontinence when compared to non-forceps delivery. The importance of an effective anal sphincter repair is confirmed. However, overall there is no direct relationship between residual sphincter damage, anal sphincter tone, and fecal incontinence severity. These data indicate that anal sphincter integrity alone is not the sole mechanism for maintaining fecal continence. Rectal and colonic motor function may also play a role and investigation into these components may provide greater insight into the effect of vaginal delivery upon fecal continence mechanisms.

It is the first birth that does the damage: a cross-sectional study 20years after delivery.

Levator ani muscle (LAM) and anal sphincter tears are common after vaginal birth and are associated with female pelvic organ prolapse and anal incontinence. The impact of subsequent births on LAM and external anal sphincter (EAS) integrity is less well defined. The objective of this study was to determine the prevalence of LAM and EAS trauma in primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally to assess if there were differences between the two groups. The null hypothesis was: there is no significant difference in the prevalence of LAM and EAS trauma between the two groups. This was a cross-sectional study involving 195 women, participants of the Dunedin arm of the ProLong study (PROlapse and incontinence LONG-term research study) seen 20years after their index birth. Assessment included a standardized questionnaire, ICS POP-Q and 4D translabial ultrasound. Post-imaging analysis of LAM and EAS integrity was undertaken blinded against other data. Statistical analysis was performed using Fisher's exact test and results were expressed as odds ratios (OR). LAM avulsion and EAS defects were diagnosed in 31 (16%) and 24 (12.4%) women respectively. No significant difference in the prevalence of levator avulsion and EAS defects between primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally (OR 1.9, 95% CI 0.72-5.01, p = 0.26) and (OR 1.2, 95% CI 0.4-3.8, p = 0.76) respectively. Most LAM avulsions and EAS defects seem to be caused by the first vaginal birth. Subsequent vaginal deliveries after the first were unlikely to cause further LAM trauma.

Does anal sphincter injury preclude subsequent vaginal delivery?

ObjectiveTo assess continence and anal sphincter integrity during a subsequent pregnancy and delivery in women known to have a previous anal sphincter injury. DesignProspective observational study. SettingThe National Maternity Hospital, Dublin, Ireland. PopulationAntenatal patients with a documented obstetric anal sphincter injury at a previous delivery. MethodsWomen underwent symptom scoring, endoanal ultrasound and manometry. Main outcome measuresRecommended and actual mode of delivery, continence scores and endoanal ultrasound findings after index delivery. Results557 women were studied. 293 (53%) had no symptoms of faecal incontinence, 189 (34%) had mild symptoms and 75 (13%) moderate or severe symptoms.408 (73%) had an endoanal ultrasound. 383(94%) had a normal or small (<1 quadrant) defect in the internal anal sphincter and 390 (96%) had a scar or small (<1e quadrant) defect in the external anal sphincter.393 (70%) delivered vaginally. 164 (30%) were delivered by caesarean section. 197/557 (35%) returned for follow-up. There was no significant change in continence following either vaginal or caesarean delivery. 20 (5.1%) women had a recognised second anal sphincter tear during vaginal delivery. ConclusionsThe majority of women who sustain a third degree tear have minimal or no symptoms of faecal incontinence when assessed antenatally in a subsequent pregnancy. 70% go on to have a vaginal delivery, with little impact on faecal continence. These findings provide reassurance for patients and clinicians about the safety of vaginal delivery following anal sphincter injury in appropriately selected patients.

Impact of Patient Age on Procedure Type for Ulcerative Colitis: A National Study.

Historically, older patients with ulcerative colitis were not considered candidates for ileal pouch-anal anastomosis. However, more recent evidence suggests that this procedure can be performed in older patients with acceptable surgical and functional results. The purpose of this work was to determine whether older age is independently associated with surgical procedure type among patients with ulcerative colitis in a large national database. This was a cross-sectional analysis of ulcerative colitis patients undergoing end ileostomy or IPAA, grouped by age. This study was conducted in a university teaching hospital. Patients with ulcerative colitis who underwent total proctocolectomy or completion proctectomy with either IPAA or end ileostomy from 2005 to 2012 in the American College of Surgeons National Surgery Quality Improvement Program database were included in this study. The primary outcome was procedure type (end ileostomy or IPAA). Patient factors associated with procedure type, including age and trends over time, were examined using multivariate logistic regression. Among 3635 patients with ulcerative colitis, 28.2% underwent end ileostomy and 71.8% underwent IPAA. Older patients were more likely to undergo end ileostomy than patients ≤50 years of age after adjustment for sex, smoking, BMI, frailty trait count, and ASA class (p < 0.001). The odds of end ileostomy decreased by 12% per year between 2005 and 2012 in patients aged 61 to 70 years compared with patients ≤50 years of age (adjusted OR, 0.88 per year; p = 0.021). We were unable to analyze other potentially important determinants of procedure type, such as surgeon, patient preference, and anal sphincter integrity. Age remains strongly associated with procedure type. The use of end ileostomy, however, is decreasing over time in patients 61 to 70 years of age as evidence accumulates that IPAA is an acceptable option for older patients with ulcerative colitis (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A191).

Screening occult anal sphincter injuries in primigravid women after vaginal delivery with transperineal use of vaginal probe: a prospective, randomized controlled trial.

Here we aimed to evaluate the incidence of obstetric anal sphincter injuries in spontaneous primigravid deliveries with mediolateral episiotomy beyond 36 gestational weeks. We performed a prospective, randomized controlled study including 201 primigravid women that delivered vaginally. Anal sphincter anatomy and integrity was evaluated before hospital discharge in all cases with transvaginal sonography (5-9MHz) (Siemens Sonoline G50 and Voluson 730 Expert). The vaginal ultrasound probe is placed in the fourchette of the vaginal introitus to obtain the transverse section of the anal sphincter. In the cases with sphincter defect, mean gestational week and second stage of labor were prolonged significantly (p=0.039 and p<0.0001, respectively). The mean perineal body distance in cases with sphincter injury, as detected by sonography, 2.18±0.33cm, is compared to 2.31±2.43cm in cases without injury. There was a significant difference between the two groups (p=0.0142). Shoulder dystocia was significantly higher in cases with sphincter injury, compared to cases without injury (p=0.011). No clinical findings were reported in 11.5% of cases (Sonography findings 1A∓, 1B∓) and 3.5% of cases had clinical and sonographic findings (Sonography findings 2A∓, 2B∓). "Occult tears" were considered as those cases not detected clinically, but detected by sonography (11.5% of all cases). Two months after examination, a moderate incontinence (Wexner continence scale) was found in 71.5% of cases with overt sphincter tear, which was significantly different to the non-overt sphincter tear group. Multiple logistic regression analyses for sphincter injuries identified prolonged second stage of labor and shoulder dystocia as two independent risk factors. Here, we found that only a portion of anal sphincter injuries can be detected after physical examination, with many of cases of "occult tears" escaping notice. These cases of occult anal sphincter injury are detectable by sonography with transperineal use of a vaginal probe. Based on these findings, we propose that this technique is convenient for obstetric, gynecologic and proctologic evaluation of sphincter anatomy.

Effect of endorectal pullthrough on external anal sphincter integrity (in cases of Hirchsprung’s disease) using EMG

ObjectiveThe transanal mucosectomy of the aganglionic segment is a critical step in the transanal endorectal pullthrough procedure for the treatment of Hirchsprung’s disease. It exerts considerable traction on the anorectal tissue during dissection. Anal sphincter electromyography (EMG) is an indisp

Incontinence after primary repair of obstetric anal sphincter tears is related to relative length of reconstructed external sphincter: a case–control study

To determine if anatomic primary repair with end-to-end reconstruction of the external anal sphincter (EAS) in its full length combined with separate repair of coexisting internal anal sphincter (IAS) tear, when present, results in less incontinence and better anal sphincter integrity compared with conventional primary end-to-end repair in which the IAS is not actively reconstructed. Women who sustained third- or fourth-degree obstetric tears were included prospectively in the study following anatomic primary repair. Women treated with conventional primary repair prior to the study period comprised the control group. Three-dimensional endoanal ultrasonography (3D-EAUS) images were classified according to the EAUS defect score, and incontinence according to St Mark's score. Sixty-three women were included in the study group and 61 in the control group, with mean follow-up times of 11 and 21 months, respectively. Among women who had not delivered vaginally prior to the tear, St Mark's score ≥ 3 was reported by 9.6% (5/52) in the study group and 37.5% (15/40) in the control group at follow-up (P = 0.002). The corresponding numbers among women who had previously delivered vaginally were 36.4% (4/11) and 42.9% (9/21), respectively (non-significant). St Mark's score correlated with the EAUS defect score (P = 0.017). An EAS defect exceeding 50% of the sphincter length was significantly less common in the study group, and in a multivariable logistic regression model, mode of repair (anatomic vs conventional) was the only factor explaining the difference in EAS sphincter length between the two groups (P = 0.007). Improved continence status after anatomic primary repair was associated with a better longitudinal reconstruction of the EAS, while the integrity of the IAS did not differ between the groups. Women with a history of vaginal delivery prior to the sphincter tear had an inferior outcome regardless of mode of repair.

Anal vector volume analysis: an effective tool in the management of pelvic floor disorders

Different trials have investigated the role of conventional anal manometry in the diagnosis of pelvic floor disorders. The aim of the present study is to define the role and the effectiveness of vector anal manometry and vector asymmetry index scoring in the assessment of pelvic floor disorders i.e. fecal incontinence and obstructed defecation. Between 2005 and 2007, 387 patients underwent clinical and manometric evaluation in the Department of Surgery, University Hospital Tor Vergata, Rome, Italy, and were included in the present prospective cohort study. All the patients underwent clinical examination, Wexner incontinence scoring, and anal vector manometry and were classified into three groups. Group I included patients with normal resting anal pressure values (195 patients). Groups II and III consisted of patients with resting anal pressure higher and lower than normal values, respectively (90 and 102 patients, respectively). All patients were classified into asymmetric and non-asymmetric according to the vector asymmetry index using a cut-off of 20%. We investigated the correlation between anal asymmetry and pelvic floor disorders, i.e. fecal incontinence due to sphincter injury, rectal prolapse, and obstructed defecation. In Group III, the number of asymmetric patients was significantly higher than non-asymmetric ones (P < 0.0001). Asymmetry values were significantly higher in group III than in groups I and II considering squeeze (P < 0.0001) or resting pressures (P < 0.0001). Furthermore, there was a statistically significant association between anal asymmetry and both anal incontinence (P < 0.0001) and rectal prolapse (P = 0.0270). No such association was found between anal asymmetry and obstructed defecation. Anal vector manometry using vector analysis of resting and squeeze pressures is complementary to endoanal ultrasonography, as it provides information on anal sphincter function and integrity. The vector asymmetry index >20% correlates with fecal incontinence due to anal sphincter lesions. Therefore, anal vector manometry may be useful as an independent method of screening for pregnant women at risk of sphincter injury and for patients undergoing anorectal surgery with risk factors for incontinence, like previous anorectal surgery or a history of two or more previous vaginal deliveries.

Temporal endosonographic evaluation of anal sphincter integrity after primary repair for obstetric ruptures: a case for specific training of obstetricians

To evaluate primary repaired obstetric lesions of the anal sphincter complex on anal endo-ultrasound within a few days and 8 weeks after primary repair and to investigate in this way the influence of suboptimal woundhealing on the final anatomical result. Furthermore to investigate the relation between faecal incontinence and sphincter defects. A prospective cohort study. Setting The obstetric clinic and coloproctology outpatient clinic of the Zaans Medical Centre in Zaandam, the Netherlands. Subjects A cohort of 32 consecutive women with primary surgically repaired 3B, 3C or 4th degree anal sphincter defect after vaginal delivery. Appearance of the anal sphincter complex on anal endo-ultrasound within a few days week and 8 weeks after primary surgical repair, i.e. first and second ultrasound, respectively. Evaluation of anal continence, using the Vaizey incontinence score, at second ultrasound. No major wound breakdown was seen and four women had superficial, skin related wound problems. Twenty-eight women (87.5%) had a repaired external anal sphincter on the first and the second ultrasound. Of four external anal sphincter defects on first ultrasound one defect was not present on second ultrasound. The internal sphincter showed a defect on first ultrasound in 11 women and this was still present in 10 on second ultrasound. A total of 11 women had a persisting anal sphincter defect (external, internal or in combination). Mean Vaizey scores were significantly higher in women with a persisting sphincter defect (EAS, IAS or in combination) than in women with no sphincter defects, 2.3 and 0.4 respectively (95% CI 0.1-3.6, P = 0.04). Anal endo-ultrasound may be used for early evaluation of surgical repair of anal sphincter lesions after vaginal delivery. Persisting defects in the anal sphincters, in this series not because of major wound breakdown, can be explained by inadequate surgical repair.

Sphincter saving anorectoplasty (SSARP) for the reconstruction of Anorectal malformations

BackgroundThis report describes a new technique of sphincter saving anorectoplasty (SSARP) for the repair of anorectal malformations (ARM).MethodsTwenty six males with high ARM were treated with SSARP. Preoperative localization of the center of the muscle complex is facilitated using real time sonography and computed tomography. A soft guide wire is inserted under image control which serves as the route for final pull through of bowel. The operative technique consists of a subcoccygeal approach to dissect the blind rectal pouch. The separation of the rectum from the fistulous communication followed by pull through of the bowel is performed through the same incision. The skin or the levators in the midline posteriorly are not divided. Postoperative anorectal function as assessed by clinical Wingspread scoring was judged as excellent, good, fair and poor. Older patients were examined for sensations of touch, pain, heat and cold in the circumanal skin and the perineum. Electromyography (EMG) was done to assess preoperative and postoperative integrity of external anal sphincter (EAS).ResultsThe patients were separated in 2 groups. The first group, Group I (n = 10), were newborns in whom SSARP was performed as a primary procedure. The second group, Group II (n = 16), were children who underwent an initial colostomy followed by delayed SSARP. There were no operative complications. The follow up ranged from 4 months to 18 months. Group I patients have symmetric anal contraction to stimulation and strong squeeze on digital rectal examination with an average number of bowel movements per day was 3–5. In group II the rate of excellent and good scores was 81% (13/16). All patients have an appropriate size anus and regular bowel actions. There has been no rectal prolapse, or anal stricture. EAS activity and perineal proprioception were preserved postoperatively. Follow up computed tomogram showed central placement the pull through bowel in between the muscle complex.ConclusionThe technique of SSARP allows safe and anatomical reconstruction in a significant proportion of patients with ARM's without the need to divide the levator plate and muscle complex. It preserves all the components contributing to superior faecal continence, and avoids the potential complications associated with the open posterior sagittal approach.

Prospective randomised study of urgent haemorrhoidectomy compared with non‐operative treatment in the management of prolapsed thrombosed internal haemorrhoids

To compare the outcome of urgent haemorrhoidectomy with conservative treatment for prolapsed thrombosed internal haemorrhoids. A prospective randomised study of 50 patients with prolapsed thrombosed internal haemorrhoids was carried out using clinical and ultrasonic outcome measures. Peri-operative bed occupancy and the presence of symptoms at 6 and 24 months were compared. Endoanal ultrasonic scanning was carried out to investigate anal sphincter integrity in those patients willing to be studied. The median length of hospital stay for the group treated conservatively; 2 nights (range 1-9 nights) was significantly shorter than for the group treated by urgent haemorrhoidectomy; 4 nights (range 1-12 nights, P < 0.01). There was no difference between treatment groups in the number of patients with symptoms at six or 24 months. Urgent haemorrhoidectomy was associated with a significantly higher incidence of endosonographically detected anal sphincter damage in 18 patients: 66%vs 0% (P = 0.009). Conservative treatment for prolapsed thrombosed internal haemorrhoids is associated with shorter in patient stay and less anal sphincter damage compared with operative treatment.