Anal Sphincter Pressure Research Articles

Childhood Constipation: Is There New Light in The Tunnel?

IntroductionConstipation is a common phenomenon in childhood worldwide. The symptoms vary from mild and short-lived to severe and chronic with faecal impaction and encopresis. Although our understanding of pathophysiology has grown rapidly in recent decades, the causes and management of constipation

Sphincter rupture and anal incontinence after first vaginal delivery.

The aim of this prospective study was to establish the incidence of anal incontinence and sphincter defects after first vaginal delivery. A total of 99 nulliparous and pregnant women were examined prospectively 4 weeks (mean) before delivery and 4 months (mean) after delivery. Of the study population, 75 (76%) women had vaginal delivery and 24 (24%) had cesarean section. Vacuum extraction was necessary in 20 (20%) cases. The symptoms of anal incontinence were asked about using a standard questionnaire. Clinical examination, endoanal ultrasound (EAUS) and anal manometry were performed before and after delivery. The symptoms of mild anal incontinence, mainly gas incontinence, increased after vaginal delivery more than after cesarean section (P < 0.032). Occult anal sphincter defects were noted in 17 (23%) of the 75 women after vaginal delivery by using EAUS. After vacuum extraction, anal sphincter defects were noted in nine (45%) out of 20 women. No new sphincter defects were found in the cesarean section group. The maximal squeezing pressures were significantly decreased in the patients with external anal sphincter (EAS) defects (P = 0.0025). Vacuum extraction leads to more sphincter defects but does not significantly increase anal incontinence or decrease mean anal sphincter pressures. The first vaginal delivery can result in occult sphincter defects and the use of vacuum extraction increases the risk.

Thickening of the internal anal sphincter in idiopathic constipation in children.

Thickening of the internal anal sphincter (IAS) is observed in chronic idiopathic constipation (IC) and solitary rectal ulcer syndrome (SRUS), where it has been correlated with the presence and severity of rectal intussusception. Alternatively, thickened IAS may be a feature of the obstructed megarectum in a similar way to the hypertrophy of bladder neck seen in dyssynergic bladders. The aim of this study was to investigate the significance of thickening of the IAS in children with chronic IC and to determine any association between the thickened IAS and anorectal manometry findings and patient's symptoms. A total of 144 children were admitted for investigations and treatment of chronic IC and evaluated prospectively between April 2001 and April 2003. IAS thickness was measured by endosonography using B&K axial endosonic probe type 1850 with a 10-MHz rotating transducer. The thickness of IAS was measured at 3, 6, and 9 o'clock, and the mean value of the three measurements was used for analysis. Functional assessment was done by anorectal manometry pressure studies under ketamine anaesthesia. A validated symptom score (SS) was used to assess the severity of symptoms. The sum of SS ranged between 0 and 65. Spearman's rho two-tailed test was used to correlate the thickness of IAS with patients' symptoms and anorectal manometry findings. Results were expressed as median and range and p-value of less than 0.05 was considered significant. Of 144 children, 84 were boys, median age 8.1 years (range 3.1-15). Soiling was present in 137 (94%) patients, delay in defecation in 132 (91%), and a palpable megarectum on abdominal examination in 117 (80%). The median duration of symptoms and duration of laxative treatment were 4 years (range 0.3-14.5) and 3.3 years (0.2-13.5), respectively. The average severity score for soiling, delay in defecation, palpable megarectum, and the total SS were 8 (range 0-10), 5 (0-10), 2 (0-12), and 33 (11-51), respectively. The median thickness of IAS was 0.9 mm (range 0.3-2.8) and the median resting anal sphincter pressure was 54 mmHg (19-107). The median amplitudes of rectal and anal sphincter contraction were 3 mmHg (1-25) and 9 mmHg (1-35), respectively. The thickness of IAS correlated significantly with total symptom severity score (r=0.31, p=0.0001), soiling score (r=0.28, p=0.001), megarectum score on abdominal palpation (r=0.29, p=0.001), size of megarectum on manometry (r=0.36, p=0.0001), amplitude of rectal contraction (r=0.23, p=0.007), and age of patient (r=0.55, p=0.0001). There was also a significant correlation between the amplitude of rectal and anal sphincter contraction (r=0.32, p=0.0001). There was no correlation between thickness of IAS and resting anal sphincter pressure and amplitude of anal sphincter contraction on anorectal manometry study. A total of 24 children had myectomy of thickened and overactive IAS in addition to the medical treatment of their chronic IC. The histology examination of myectomy specimen with eosin and haematoxylin staining and histochemical acetylcholine esterase staining showed smooth muscle fibres and ganglion cells. Thickening of IAS correlates significantly with duration and severity of symptoms, size of megarectum, and amplitude of rectal contraction. The pathogenesis is secondary to the continuous presence of faeces in the rectum, resulting in chronic abnormal stimulus to the IAS, which leads to hypertrophic changes in the rectum wall and IAS.

La Tossina Botulinica Tipo a Nel Trattamento Della Prostatite non Batterica: Studio Prospettico di Fase II

Nowadays aetiology, diagnosis and therapy of chronic non bacterial prostatitis are not still universally valuated in international urologic consensus. Recently, the National Institute of Health (N.I.H.) of USA suggested new staging of prostatitis. The aim of the study was to demonstrate the effectiveness of american botulinum toxin injected in external striated urinary sphincter in stage 3a and 3b patients according to NIH classification, with high medium and maximal closure pression of the external anal sphincter, demonstrated at the anorectal manometry. Methods. In our ongoing prospectic phase II study, the patients diagnosed to have 3a e 3b prostatis according to NIH classification after Meares-Stamey test, underwent ultrasonography of the whole abdomen, anorectal manometry, uroflowmetry, NIH symptom score (NIH-CPSI). Twentyone patients had elevated medium and maximal closure pressure of the striated anal sphincter and were included in the study. American botulinum toxin 100 unit intraperineal injection was given in these patients. One and six months control uroflowmetry and NIH-CPSI were evaluated. Results were processed with chi-square test (significant for p&lt;0.05). Results. One and six months results were significant in respect to baseline values regarding TQ (p&lt;0.0001), max TQ (p=0.0002) e NIH-CPSI (p&lt;0.0001). Conclusion. Botulinum toxin is safe and effective in relieving symptoms of 3a and 3b prostatitis patients with high striated anal sphincter pressure.

Functional magnetic stimulation of the spinal cord--a urodynamic study in healthy humans.

To study the effects of functional magnetic stimulation of the spinal cord in healthy subjects on somatic and autonomic pathways innervating the anal and the external urethral sphincter, bladder, bladder neck, and rectum. Eight healthy male volunteers gave their written informed consent and underwent functional magnetic stimulation of the thoracolumbar and sacral spinal cord. A two-channel microtip pressure transducer catheter was placed rectally measuring the abdominal and anal sphincter pressure. A three-channel microtip pressure transducer catheter was inserted into the urethra measuring the bladder, the bladder neck, and the external urethral sphincter pressure. A comprehensive protocol of single and repetitive magnetic stimulations was performed. Frequency, location, and duration of stimulation were varied while the intensity of stimulation was adapted to the maximum the subjects could tolerate. In four subjects, the degree of bladder filling was changed and the protocol was repeated when the subjects reported a full bladder and desire to void. Continuous magnetic stimulation of the thoracolumbar spinal cord and the sacral roots applied with different frequencies (5, 15, 30, 60, 100 Hz) and different duration of stimulation (10, 30, 120 sec) evoked sphincter contraction of both anal and urethral sphincters. The stimulation could not evoke contractions of the bladder, the bladder neck, or the rectum. Also with filled bladder and present desire to void, the magnetic stimulation could not activate autonomic pathways innervating these structures. Considering our results, we suggest that in individuals with preserved sensibility magnetic stimulation of the spinal cord with intensities below the pain threshold is ineffective in activating autonomic nerve fibres innervating bladder, bladder neck, and rectum.

Primary sphincter repair: are the results of the operation good enough?

This study was designed to evaluate the clinical outcome of primary anal sphincter repair caused by obstetric tears and to analyze possible risk factors associated with sphincter rupture during vaginal delivery. A total of 52 females with a third-degree or fourth-degree perineal laceration during vaginal delivery were examined. The symptoms of anal incontinence were obtained by a standard questionnaire. In addition to a clinical examination, endoanal ultrasound, anal manometry, and pudendal nerve terminal motor latency examinations were performed. A control group consisted of 51 primiparous females with no clinically detectable perineal laceration after vaginal delivery. After primary sphincter repair, 31 females (61 percent) had symptoms of anal incontinence. Fecal incontinence occurred in 10 females (20 percent). According to Hardcastle and Parks' and Jorge and Wexner's classifications, the study group had more severe symptoms of anal incontinence than the control group (P<0.001 in both classification groups). In endoanal ultrasound examination, a persistent defect of the external anal sphincter was found in 39 females (75 percent) in the rupture group compared with 10 females (20 percent) in the control group (P<0.001). Anal sphincter pressures were significantly lower in the rupture group than in the control group. An abnormal presentation was the only risk factor for anal sphincter rupture during vaginal delivery. After primary sphincter repair, persistent external anal sphincter defect and symptoms of anal incontinence are common in females who have had a primary sphincter repair after vaginal delivery. The means of improving the results of primary repair should be studied further.

Sphincter rupture and anal incontinence after first vaginal delivery

Background. The aim of this prospective study was to establish the incidence of anal incontinence and sphincter defects after first vaginal delivery. Methods. A total of 99 nulliparous and pregnant women were examined prospectively 4 weeks (mean) before delivery and 4 months (mean) after delivery. Of the study population, 75 (76%) women had vaginal delivery and 24 (24%) had cesarean section. Vacuum extraction was necessary in 20 (20%) cases. The symptoms of anal incontinence were asked about using a standard questionnaire. Clinical examination, endoanal ultrasound (EAUS) and anal manometry were performed before and after delivery. Results. The symptoms of mild anal incontinence, mainly gas incontinence, increased after vaginal delivery more than after cesarean section (P < 0.032). Occult anal sphincter defects were noted in 17 (23%) of the 75 women after vaginal delivery by using EAUS. After vacuum extraction, anal sphincter defects were noted in nine (45%) out of 20 women. No new sphincter defects were found in the cesarean section group. The maximal squeezing pressures were significantly decreased in the patients with external anal sphincter (EAS) defects (P = 0.0025). Vacuum extraction leads to more sphincter defects but does not significantly increase anal incontinence or decrease mean anal sphincter pressures. Conclusions. The first vaginal delivery can result in occult sphincter defects and the use of vacuum extraction increases the risk.

Outcome measures for fecal incontinence: anorectal structure and function

Fecal incontinence is a symptom attributable to a variety of disorders affecting one or more factors that maintain continence. Objective assessments should complement symptom assessments as outcome measures in therapeutic trials; conceivably, these assessments may also predict the response to therapy. Consistent with existing trends, most therapeutic trials should incorporate anal sphincter pressures and rectal sensation as outcome variables, paying meticulous attention to techniques. Rectal sensation is increased after pelvic floor retraining by biofeedback therapy in fecal incontinence; however, the predictive value of improved anal pressures after biofeedback has not been clearly established. Other factors maintaining continence can be assessed by newer approaches. In addition to assessing rectal sensation, a barostat also measures rectal compliance; alterations in rectal compliance modulate rectal perception. Particularly appropriate end points for trials involving surgical repair are sphincter integrity, assessed by endoanal ultrasound or magnetic resonance imaging (MRI), and puborectalis and pelvic floor motion, assessed by dynamic MRI. Despite disagreement about which technique is superior for evaluating the internal sphincter, MRI performs the same or better than ultrasound for assessing the external sphincter. The utility of measuring pudendal nerve latencies as a marker of pudendal nerve injury is limited; needle electromyography provides a sensitive measure of denervation and can usually identify myopathic damage, neurogenic damage, or mixed injury. These standardized, reproducible assessments of the multifaceted mechanisms maintaining fecal incontinence should be incorporated as outcome variables in therapeutic trials of fecal incontinence.

Maturation of the rectoanal inhibitory reflex in very premature infants

ObjectiveTo characterize anal sphincter function in very premature infants ≤30 weeks' postmenstrual age (PMA) and to evaluate the time of maturation of the rectoanal inhibitory reflex (RAIR) by using a sleeve catheter. Study designAnorectal manometry was performed in 16 healthy neonates (nine girls) with a mean PMA of 29 weeks (range, 27–30 weeks) and a birth weight of 640 to 1590 g (median, 1220 g) with a micromanometric assembly (outer diameter, 2.0 mm). The assembly incorporated a 1.5-cm-long sleeve sensor for measurement of resting anal sphincter pressures and relaxation, and four side holes recorded anal and rectal pressures. Rectal distention was performed with direct air insufflation to elicit the RAIR. ResultsThe mean anal sphincter pressure, rectal pressure, and anal sphincter oscillation frequency were 24.5±11.4 mm Hg, 6.5±4.8 mm Hg, and 11.1±2.3/min, respectively. A normal RAIR could be elicited in 13 (81%) infants studied. In two infants, the RAIR could not be elicited because of a low anal sphincter pressure of only 5 mm Hg. In the other child, no RAIR was seen despite the repeated insufflation of at least 5 mL of air. ConclusionThe majority (81%) of premature infants older than 26 weeks' PMA have normal anorectal pressures and a normal RAIR.

Cerebral cortical representation of external anal sphincter contraction: effect of effort.

The external anal sphincter (EAS) plays a critical role in maintaining fecal continence; however, cerebral cortical control of voluntary EAS contraction is not completely understood. Our aims were to determine the cortical areas associated with voluntary EAS contraction and to determine the effect of two levels of sphincter contraction effort on brain activity. Seventeen asymptomatic adults (ages 21-48, 9 male) were studied using functional magnetic resonance imaging (fMRI) to detect brain activity. Studies were done in two stages. In stage 1 (10 subjects, 5 male), anal sphincter pressure was monitored from a catheter-affixed bag. Subjects performed maximal and submaximal EAS contractions during two fMRI scanning sessions consisting of alternating 10-s intervals of sustained contraction and rest. In stage 2 studies, seven subjects (4 male) performed only maximum effort sphincter contractions without a catheter. EAS contraction was associated with multifocal fMRI activity in sensory/motor, anterior cingulate, prefrontal, parietal, occipital, and insular regions. Total cortical activity volume was significantly larger (P < 0.05) for maximal (5,175 +/- 720 microl) compared with submaximal effort contractions (2,558 +/- 306 microl). Similarly, percent fMRI signal change was significantly higher (P < 0.05) for maximal (4.8 +/- 0.1%) compared with submaximal effort contractions (2.2 +/- 0.1%). Cortical region-of-interest analysis showed the incidence of insular activation to be more common in women compared with men. Other cortical regions showed no such gender differences. fMRI activity detected in stage 2 showed similar regions of cortical activation to those of the stage 1 study. Willful contraction of the EAS is associated with multifocal cerebral cortical activity. The volume and intensity of cerebral cortical activation is commensurate with the level of contractile effort.

Chemical Sphincterotomy for Anal Fissure

Summary Six hundred and forty patients (65 of them were children) with acute and chronic anal fissure were randomized to receive topical 0.2%-0.8% Glyceryl trinitrate (G.T.N.) or Isosorbide dinitrate (ISDN) 1%-3% three times daily digitally applied ointment. Patients were followed for 6-26 months. A course of 2-6 weeks treatment was needed. Resting and maximum anal sphincter pressure (MARP) were measured by manometry for 40 patients and showed a very significant decrease in maximum anal sphincter pressure after application of ointment with progress of days of treatment (p =0.02). After 1-2 weeks of treatment 90.4% of acute fissure patients were free of symptoms and 83.73% of them were later cured. Four to eight weeks of treatment were needed to abolish pain in 85.5% chronic fissure patients, and cure was clear in 80% of them (p = 0.008). Side effects of treatment were negligible. Recurrence rate was 4%, while 24 patients (3.8%) were sent for internal sphincterotomy and 81 patients (12.6%) requested revision of medical treatment. In this study we concluded that surgery can be avoided in most cases of anal fissure, and it kept for recurrent cases. Recurrent cases after surgery can also be treated medically.

What is the optimum methodology for measuring resting anal sphincter pressure?

1-wo recently pub1 sbed guidelines 'ior anorectaI nranometric testing are contradictory ~x~garding dleir tecommenda ions tot he method for assessing resting anal sphincter pressure (pull-through vs s ationa U techniques) Aims: I To evaluate and compare three methods of measnrrng reslfr:g anal pressme in patients with constipation and pdvtc floor dysfunction (C) and { mc tonal tecal incontine~rce (FIt. 2 To determine the method(s) which best predicts C or FI Me hods: Water perhlsed a~,orectal nnmomerty was performed in 47 patients (15C, mean age 38 yrs 121: 32FI, age 56 27F) k computerised manometric technique with a 7 port muhihamen catheter ((~2 De~atsleeve) with ports 0.Ycm apart was used. Each patient m~derwent each o the thllowmg assessments: I Stationary resting anal sphincter pressure over 3 minutes 2 Slow pulI~thmngh 5mm/Ysec 3 Rapid pull-through 5mrrVsec Resnlts: The mean ~vsting anal spirit:clef pressure was significantly dill%rein across the three methods (stationary 66 +/-4mmHg, slow p'all-thmugh 96 +/-5mmHg rapid pull-through 107 +/6mmHg p is essential for comparison of patient groups Diamant et al Gas roente~oogy !999 Ran et al Neurogastrtwnterol Mot 2002

OC178: Endosonographic anal sphincter defect classification after primary repair of obstetric sphincter tears: relation to sphincter pressure and anal incontinence

Objective: To classify endosonographic obstetric sphincter defects and relate the endosonographic results to anal sphincter pressure and symptoms of anal incontinence. Methods: Forty-one women who had undergone primary repair of third or fourth degree perineal tear at delivery underwent anal endosonography and anal manometry at 1 week, 3 months and 1 year after the tear. The extension of the endosonographic defects were classified using scores (1–16; the higher the score the larger the defect). The women answered a questionnaire with regard to bowel function at 1 and 4 years after delivery. Wexner incontinence score (1–20) was used for classification of anal incontinence. Results: 90% of the women had endosonographic defects at 1 week, 3 months and 1 year. The endosonographic defect scores increased significantly between the first and the second examination, then remained unchanged. At 1 and 4 years 54% and 61% of the women, respectively, reported anal incontinence. At 1 year there was a negative correlation between endosonographic sphincter defect score and sphincter pressure (resting pressure: r2 = 0.39, p < 0.0001; squeeze pressure: r2 = 0.16, p = 0.01; resting pressure area: r2 = 0.29, p = 0.0003). There was a positive correlation between endosonographic sphincter defect score at 1 year and incontinence score at 1 year (r2 = 0.13, p = 0.02) and 4 years (r2 = 0.22, p = 0.002). Multiple linear regression analysis showed resting pressure to be the only variable to independently predict Wexner score at 1 year and endosonographic defect score to be the only variable to independently predict Wexner score at 4 years. Conclusion: Endosonographic sphincter defects are common after primary suture of obstetric sphincter tears. The more damaged the sphincter appears to be at endosonography, i.e. the higher the endosonographic defect score, the lower is the sphincter pressure and the higher is the incontinence score.

A prospective evaluation of anorectal function after total mesorectal excision in patients with a rectal carcinoma

Background. Rectum resection with total mesorectal excision (TME) and neorectal anastomosis often compromises anorectal function. Insight into the underlying mechanisms is lacking. Therefore, a prospective study was designed to investigate the relationship between clinical and functional outcomes preoperatively and postoperatively. Methods. Eleven patients with rectal cancer were examined before and 4 and 12 months after surgery and compared with 11 healthy volunteers (HVs). Anorectal (neorectal) function was examined by clinical outcome questionnaire, anal manometry, rectal compliance, and sensation. Six HVs also underwent barostat measurements in the sigmoid colon. Results. Clinical parameters of soiling and passive incontinence (loss of stool without sensation) increased significantly until 12 months postoperatively, whereas urgency and tenesmus increased temporarily, returning to preoperative values at 12 months. In anorectal measurements, anal sphincter function was grossly preserved; however, rectal-anal inhibitory reflex (RAIR) was decreased at 4 months but recovered after 1 year. Neorectal compliance was similar to that of HV sigmoid, increasing slightly after 12 months but still significantly lower than that of normal rectum. Neorectal sensation to pressure distention was similar to that of normal rectum, however accompanied by smaller volumes. Neorectal distention induced contractions of large amplitude at 4 months, returning to normal after 12 months. Conclusions. Our results suggest that the transient increase in urgency and tenesmus after surgery results from a temporary increase in neorectal “irritability” accompanied by some adaptation of compliance in time. In contrast, episodes of incontinence and soiling are increased after 1 year most likely because of reduced neorectal capacity and RAIR recovery in the presence of a low basal anal sphincter pressure. (Surgery 2003;133:56-65.)

Radio Frequency Surgery: A New Treatment Technique Of Fissure In Ano And Associated Pathologies

Background-Anal fissures are dealt with the traditional approaches aiming at relieving the anal spasm and minimizing the anal sphincter pressure. Nevertheless, for concomitant pathologies like sentinel tags, anal papillae, or small hemorrhoids, nothing specific is done. Materials and MethodsIn this study, a description is made about a combined approach of relieving the anal spasm by anal stretching followed by radio frequency surgical procedures to eliminate the associated pathologies mentioned. ResultsAll the patients treated by the method of anal dilatation followed by radio frequency surgical procedure for aforesaid associated pathologies were comfortable due to reduction in pain and irritation during defecation, the pricking or foreign body sensation in the anus, and pruritus or wetness around the anal verge. A follow up after 12-15 months showed no recurrence of symptoms or local signs. ConclusionA combined approach by anal stretching and radio frequency surgery had been found to be very effective, easy and hassle free way of treating chronic fissure with associated pathologies. Except the radio frequency unit, the procedure needs no specialized instruments and the procedure can be performed in any routine surgical set up. Reduced hospital stay, early return to work, and minimum chances of recurrence of the problem are the noteworthy achievements of the radio frequency surgery technique.

Perioperative Resting Pressure Predicts Long-Term Postoperative Function After Ileal Pouch–Anal Anastomosis

The purpose of this study was to determine whether perioperative manometry is useful in predicting long-term functional status after ileal pouch–anal anastomosis (IPAA). Prospectively collected perioperative anal manometry data from 1439 patients undergoing IPAA from 1986 to 2000 were compared to postoperative functional status at various time intervals from 6 months to 8 years after IPAA. A validated questionnaire was used to obtain information regarding restrictions of diet, work, social and sexual activity, urgency, fecal seepage or incontinence, energy level, satisfaction with surgery, and quality of life. The presence of seepage and the degree of incontinence were compared to the patient's perceived quality of life, health, energy level, and satisfaction with surgery. Low (<40 mm Hg) pre- and postoperative resting pressures were associated with increased seepage, pad use, and incontinence. Patients with low resting pressures also reported diminished quality of life, health, energy level, and satisfaction with surgery. There was a significant association ( P < 0.001) between seepage and degree of incontinence and quality of health, quality of life, energy level, and level of satisfaction with surgery. Perioperative resting anal sphincter pressures greater than 40 mm Hg are associated with significantly better function and quality of life after ileal IPAA. Improved functional outcome is associated with better quality-of-life outcomes. Low preoperative resting pressures do not preclude successful outcome after IPAA. ( J Gastrointest Surg 2002;6:316–321.)

General geriatrics and gastroenterology: constipation and faecal incontinence

The incidence of constipation increases with age but no consistent changes of colonic or anorectal motility have been shown in elderly people. Instead, neurological diseases, constipating drugs, bedriddenness and weak straining ability may explain this increased prevalence of constipation. The amount of dietary fibre in the diet may be reduced because of poor chewing ability. Parkinson's disease is accompanied by both slow colonic transit and impaired relaxation of the anal sphincter. Drug-induced constipation is particularly likely with anti-parkinsonism drugs (either anti-cholinergic or dopaminergic) and also with tricyclic anti-depressants, opiates, iron, anti-convulsants and aluminium- or calcium-containing antacids. The prevalence of faecal incontinence is also increased in elderly people. About half of frail bedridden institutionalized patients are incontinent. Anal sphincter pressures tend to be lower, but variables of sensitivity are not. In bedridden people faecal impaction may occur. The ensuing rectal distension leads to relaxation of the internal sphincter and hence to faecal soiling. The condition is often overlooked though correct diagnosis is rather simple, being made with a digital rectal examination.

Incontinence anale : étude échographique et manométrique

Study aim: The goal of this study was to evaluate the clinical and functional consequences of anal sphincter echographic lesions in patients with fecal incontinence. Patients and method: From January 1997 to April 2001, 100 patients with fecal incontinence (90 women, 10 men) were prospectively explored by transanal ultrasound and vectormanometry. Internal and external sphincter defects, as well as their extension, were analyzed with regard to their clinical and functional expressions (resting and squeeze anal sphincter pressures, anal sphincter asymetry index). Results: Among the 100 patients, 42 had no echographic lesions, 58 had a defect : 26 had an isolated defect (internal sphincter ( n=3), external sphincter ( n=23) and 32 had combined internal and external sphincter defects. Squeeze anal pressures were significantly lower in the group of patients with combined defects, compared to the group with isolated defect or without defect. Anal asymetry index was higher in the group of patients with combined defects, compared to the other groups. There was a positive correlation between the radial extension of the defect and the importance of clinical complaints. Conclusion: Echographic anal sphincter lesions are frequent in fecal incontinence and are clinically and functionally significant.

Effect of topical glyceryl trinitrate on anodermal blood flow in patients with chronic anal fissures.

Recent studies have highlighted the role of increased internal anal sphincter pressure and decreased anodermal blood flow in the pathogenesis of chronic anal fissures. The duration of the effect of topical 0.2% glyceryl trinitrate (GTN) ointment on anodermal blood flow in fissure and normal areas was investigated in patients with chronic anal fissures. Six patients with chronic anal fissures in the posterior midline participated in the study. Blood flow measurements were performed on the anoderm using laser Doppler flowmetry before and immediately after the topical application of 0.2% GTN ointment and subsequent readings were taken at 5, 15, 30, 45 and 60 min in all four quadrants. The mean anodermal blood flow in the fissure region is significantly lower than the mean blood flow of the rest of the anoderm before 0.2% GTN ointment is applied (228.7 +/- 61.8 flux units vs 439.3 +/- 25.5 flux units, respectively; P < 0.05). Immediately after the application of local 0.2% GTN ointment there is a significant increase in anodermal blood flow over the anal fissure region (457.8 +/- 56.5 flux units; P < 0.05) compared to the rest of the anoderm (457.4 +/- 30.8 flux units). This increase is most marked at 5 min post-GTN ointment application in the fissure area (474.6 +/- 41.1 flux units) and the blood flow in the fissure region is consistently above the rest of the anoderm for most of the 60 min. There is clearly reduced blood flow to the chronic anal fissure region compared to the rest of the anoderm. Topical application of glyceryl trinitrate ointment seems to significantly improve the blood flow to the fissured area in the first hour. This may therefore help in the healing of chronic anal fissures.

Characterization of anorectal pressure and the anorectal inhibitory reflex in healthy preterm and term infants

Objectives: To evaluate anorectal motor function in healthy premature and term infants with the use of micromanometric techniques. Study design: Anorectal manometry was performed in 22 healthy neonates (9 female) with a mean postmenstrual age of 32 weeks (range, 30 to 38 weeks) with a micromanometric anorectal assembly (od 2.0 mm). The assembly incorporated a 2-cm-long sleeve sensor for measurement of resting anal sphincter pressures and relaxation, and 4 sideholes recorded anal and rectal pressures. Rectal distension was performed with a latex balloon or direct air insufflation to elicit the anorectal inhibitory reflex (AR). Results: The mean anal sphincter pressure, rectal pressure, and rhythmic wave frequency were 40 mm Hg (range, 7 to 65 mm Hg), 11 mm Hg (range, 1 to 27 mm Hg), and 10/min (range, 8 to 14/min), respectively. A normal AR could be elicited in 21 of the 22 infants studied. Conclusion: An anorectal micromanometric sleeve catheter is suitable for use in evaluating anorectal pressures in preterm and term neonates. Insufflation of air without the use of a balloon to elicit the AR is reliable and suitable for use in infants <34 weeks. Premature infants older than 30 weeks’ postmenstrual age have normal anorectal pressures and a normal AR. (J Pediatr 2001;139:233-7)