Anal Sphincter Pressure Research Articles

Multiple Rectal Polyps in a Young Woman with Constipation

A 27-year-old Asian-American woman presented for evaluation of long-standing constipation. Her first severe episode of constipation occurred at age 7 and resolved with colonic lavage. Colonoscopy at that time was normal. She then experienced complete resolution of her symptoms from ages 7 to 17, when she started again experiencing defecatory difficulties with infrequent and hard stools, difficulties with evacuation, and a sensation of incomplete rectal emptying. On presentation in July 2009, she was dependent on two Senna pills per day; without them, she would not have a bowel movement for up to 1 week. She also reported episodes of rectal bleeding or blood in toilet paper, and abdominal bloating and pain that were relieved with bowel evacuation, as well as continuous and severe straining at evacuation with a feeling of incomplete evacuation. She did not, however, use finger manipulations to facilitate defecation. Her past medical and surgical history was negative and she was using no other medications except for oral contraceptives and multivitamins. She was single, worked as a program manager, lived with her boyfriend, and exercised 3–4 times/week. She did not smoke cigarettes, and drank wine socially. She was vaccinated against human papillomavirus (HPV). Family history was significant for her mother having lung cancer and her father with diabetes mellitus; she had one healthy sister. Upon further review of systems, she reported 8 lbs of weight gain, general fatigue, headaches, and mild anxiety. Her physical examination was normal except for small external hemorrhoids. Complete blood count, comprehensive chemistry panel, and thyroid function tests were all normal. On initial assessment of her constipation, a lactulose breath test was negative. A colon transit study using Sitzmarks was normal. An anorectal motility and compliance study showed a normal anal sphincter length of 5 cm, a normal internal anal sphincter pressure of 72 mmHg, and a slightly decreased external anal sphincter pressure of 91 mmHg. Rectal sensation was impaired since she barely sensed a rectal balloon filled with 50 cc of water. The anorectal inhibitory reflex was present and elicited with 30 cc of balloon distention, thereby excluding Hirschsprung’s disease. Rectal compliance was normal, but she was unable to expel an empty rectal balloon, which was suggestive of pelvic floor dysfunction. Colonoscopy revealed multiple inflammatory polyps in the rectal vault extending circumferentially to the anorectal junction. Biopsies of the polyps were performed and were associated with significant oozing that required control with application of hemostatic clips (Fig. 1). Pathologic examination of the polyp biopsies revealed six separate fragments of rectal mucosa. Five of these fragments showed polypoid hyperplastic mucosa with areas of ulceration, consistent with rectal prolapse. One of these fragments showed an area of moderate squamous epithelial dysplasia (AIN 2). No evidence of an invasive lesion was identified (Fig. 2). Despite her previous vaccination history, HPV immunohistochemistry was positive. She was then treated with polyethylene glycol twice daily for the next 3 months with some improvement of her G. Triadafilopoulos (&) Division of Gastroenterology and Hepatology, Stanford University Medical Center, Alway Building, Room M 211, 300 Pasteur Drive, MC: 5187, Stanford, CA 94305-5187, USA e-mail: vagt@stanford.edu

Prolonged Balloon Expulsion Is Predictive of Abdominal Distension in Bloating

Abdominal bloating and distension are common in patients with constipation. The precise mechanism of abdominal distension remains uncertain. We hypothesized that constipated patients with bloating plus distension exhibit a greater degree of anorectal dysfunction, potentially affecting gas evacuation, than those without distension. Therefore, our aim was to evaluate anorectal function and other clinical features in patients with constipation who exhibit bloating with and without distension. In all, 88 female patients with abdominal bloating and either non-diarrhea irritable bowel syndrome (IBS) or functional constipation were included in the study. The presence or absence of abdominal distension was assessed according to the Rome II questionnaire, and all patients underwent comprehensive clinical assessment and anorectal function studies. Patients were divided into two groups: abdominal bloating with distension (D; n=53) and abdominal bloating without distension (ND; n=35). D featured a prolonged balloon expulsion time (P=0.005), a higher resting anal sphincter pressure (P=0.002), and a higher maximum anal sphincter squeeze pressure (P=0.015) than ND. They also experienced more bloating (P<0.001), more abdominal pain (P=0.004), harder stools (P=0.01), and more incomplete emptying (P=0.005). In logistic regression modeling, prolonged balloon expulsion time was a significant predictor of abdominal distension (P=0.018). This is the first study to show that prolonged balloon expulsion time predicts abdominal distension in patients with bloating and constipation. Hence, ineffective evacuation of gas and stool associated with prolonged balloon expulsion may be an important mechanism underlying abdominal distension.

Reduced neorectal capacitance is a more important factor for impaired defecatory function after rectal resection than the anal sphincter pressure

The role of the diverse anorectal diagnostic tools like manometry and determination of the preception threshold and the maximal tolerable volume is still a matter of debate. Currently, there is a scarcity of physiological data in the long-term follow-up of patients who underwent sphincter-preserving rectal resection. The aim of this study was therefore to perform these anorectal physiological measurements and to correlate the determined parameters with a faecal incontinence score. In 45 patients, anorectal manometry, electromyography (EMG) and neorectal volume measurements were performed 21.6 +/- 1.4 months after rectal resection. Additionally, patients answered questions to help in the determination of a modified faecal incontinence score. More than half of the patients had more than four bowel movements per day and suffered from defecatory urgency, evacuation and discrimination problems. Manometric data were not related to any functional deficits. In contrast, perception threshold and maximal tolerable volume were correlated with the faecal incontinence score. Defecatory problems especially after radiochemotherapy are still common after rectal resection and the satisfactory functionality post resection should not be oversimplified to just the number of bowel movements. A precondition of an adequate defecation is not only the integrity of the sphincter muscles, but also the recovery of the rectal reservoir function.

Anorectal manometry with water‐perfused catheter in healthy adults with no functional bowel disorders

Anorectal manometry provides an objective assessment of anal sphincter pressure and rectal sensitivity and anorectal reflexes in response to distension. However, its clinical utility is hampered by a lack of standardized protocols and normative data from healthy subjects. Previous studies have used water-perfused systems in normal subjects, but some adopted a rapid pull-through technique; others did not evaluate rectal sensations and others did not carefully exclude patients with functional bowel disorders. Objective To evaluate anorectal function in healthy adults without functional bowel disorders, using a water-perfused system with the stationary technique in order to obtain normative values for anorectal manometry. Method Fifty-two healthy volunteers with no Rome II diagnostic criteria for functional bowel disorders, including only nulliparous women, underwent anorectal manometry with a water-perfused system, according to a standardized protocol. Results Maximum squeeze pressure of the anal sphincter as well as the area under the pressure-time curve during squeeze was significantly lower in women than men (P < 0.01), while sphincter length, resting pressure, volume thresholds for reflex inhibitory recto-anal and rectal sensations were similar. Conclusions This study describes a protocol for stationary anorectal manometry using a water-perfused system, and a method for analysing the various parameters obtained during the procedure, as recently suggested in the international literature. It supplies normative data obtained in a population of healthy subjects including nulliparous women, with no functional bowel disorders.

Sacral nerve stimulation for the treatment of faecal incontinence related to dysfunction of the internal anal sphincter

In patients with faecal incontinence related to isolated internal anal sphincter (IAS) disruption, conservative management is the mainstay of treatment. Surgical repair of the internal sphincter is not successful. This study evaluated the use of sacral nerve stimulation (SNS) in those with faecal incontinence and IAS disruption in whom medical and behavioural treatments had failed. Nine patients (seven women, median age 44 years, range 39-62 years), with a history of obstetric or iatrogenic anal sphincter trauma, underwent a trial of SNS. All had passive faecal incontinence, low resting anal sphincter pressure and full thickness IAS muscle disruption of greater than 30 degrees radial extent. The effect of SNS on symptoms was measured by a bowel habit diary and validated questionnaires used to assess impact on quality of life. Eight (89%) patients benefited from temporary stimulation and proceeded to permanent device implantation. Follow-up was at a mean of 46 months (range 2-81). Faecal incontinence decreased from a mean (SD) of 9.9 (10.9) to 1.0 (2.4) episodes per week (p = 0.031), and soiling decreased from 6.1 (1.6) to 1.7 (2.4) episodes per week (p = 0.031), with chronic stimulation. At latest follow-up, three patients had no incontinence, three patients had episodes of minor soiling only, one patient had >75% reduction of incontinent episodes, and two patients remained incontinent. Sacral nerve stimulation is effective in treating faecal incontinence related to a structurally and functionally abnormal internal anal sphincter. Treatment should not be refused on the basis of IAS disruption.

Influence of Body Position on Defecation in Humans.

To compare three positions for defecation by measuring abdominal pressure and the anorectal angle simultaneously. We recruited six healthy volunteers. The videomanometric measures included simultaneous fluoroscopic images, abdominal pressures, subtracted rectal pressures and anal sphincter pressures. Three positions were used: sitting, sitting with the hip flexing at 60 ° with respect to the rest of the body, and squatting with the hip flexing at 22.5 ° with respect to the rest of the body. Basal abdominal pressure before defecation on hip-flex sitting was lower than that with normal sitting, although the difference did not reach statistical significance. Basal abdominal pressure before defecation on squatting (26 cmH2 O) was lower than that with normal sitting (P < 0.01). Abdominal pressure increase (strain) on hip-flex sitting was lower than that with normal sitting, although this difference did not reach statistical significance. Similarly, the abdominal pressure increase on squatting was smaller than that with normal sitting, and yet the difference did not reach statistical significance. The rectoanal angle on defecation on hip-flex sitting did not differ from that with normal sitting. The rectoanal angle on defecation on squatting (126 °) was larger than that with normal sitting (100 °) (P < 0.05), and was also larger than that with hip-flex sitting (99 °) (P < 0.01). The results of the present study suggest that the greater the hip flexion achieved by squatting, the straighter the rectoanal canal will be, and accordingly, less strain will be required for defecation.

Incontinence and Anal Sphincter Pressure Predicts Rectal Sensitivity During High Resolution Anorectal Manometry

Purpose: The etiology behind fecal incontinence has classically been interpreted as being secondary to a variation in the mechanical or neurological functionality of the anal sphincter. This has consequently been observed as decreased anal sphincter pressure utilizing anorectal manometry. While the clinical manifestation of reduced anal sphincter pressure is soiling, several patients with fecal incontinence complain of urgency as well. Whether this urgency is attributable to true rectal hypersensitivity or the perception of soiled material is not clear. The purpose of this study was to evaluate rectal sensitivity in patients with fecal incontinence. Methods: Consecutive FI patients referred to a tertiary care medical center presenting for high resolution anorectal manometry were eligible for analysis. Subjects were excluded if they reported a diagnosis of IBS meeting Rome I criteria, or contained possible inflammatory pathology of the rectum-including ulcerative colitis, HIV, and infection. After exclusion criteria were met, subjects were then divided into two groups: those presenting with clinical fecal incontinence and those who were not presenting for clinical fecal incontinence. Anorectal information and reason for the test was captured. The data were then compared between groups for maximum anorectal squeeze pressure, maximum resting anorectal pressure, balloon threshold for sensation of urge, and balloon threshold for first sensation. Results: 188 subjects were referred for high resolution anorectal manometry and entered into the database. Of the 188 subjects evaluated, 14 were excluded. Among the remaining 174 subjects, 83 (48%) were evaluated for clinical fecal incontinence or soiling, while 91 (52%) failed to present with this history. Incontinent subjects had significantly lower resting (49.6±3.2 vs. 69.3±3.1) and squeeze pressures (117.9±6.9 vs. 179.0±8.6) compared to control subjects in the anal sphincter (see Table 1). However, incontinent patients also manifested significant rectal hypersensitivity (see Table 1). Furthermore, only 8.7% of incontinent patients showed greater than normal volume for urge.Table 1Conclusion: Patients who reported clinical fecal incontinence manifested rectal hypersensitivity. This points to a possible adaptive rectal hypervigilance process and argues against sensorimotor neuropathy as a key cause of incontinence.

Severity of Fecal Incontinence: Symptoms and Pathophysiologic Abnormalities

Purpose: Fecal incontinence (FI), a disorder receiving increasing recognition, is actually common with a reported prevalence of 1.5-11% in the population. The relationship of symptoms of FI to physiologic abnormalities is not well-defined. Many patients who suffer from FI also suffer from urinary incontinence (UI). Aims: To determine the relationship of clinical symptoms of FI to pathophysiologic abnormalities on anorectal manometry (ARM) and to the presence of urinary incontinence. Methods: 101 patients with FI referred for ARM between Jan 2008 to Feb 2009 filled out the Rome III questionnaires for FI, the Bristol stool form scale (grading stool caliber from 1= hard stools to 7= watery stools), and the International Consultation on Urinary Incontinence Questionnaire (ICIQ). ARM included water perfused anorectal manometry, anal EMG, and balloon expulsion. Results: Amount of leakage for FI episodes was related to several physiologic abnormalities: as the FI leakage increased from small to moderate to large, the resting anal sphincter pressure decreased (71±5 vs. 58±4 vs. 44±4 mmHg, p=0.004,respectively) and the volitional anal sphincter contractile response decreased (98±9 vs. 68±7 vs. 59±17 mmHg, p=0.01, respectively), and the sensory threshold increased (22±1 vs. 23±1 vs. 30±4 ml, p=0.01, respectively). The type of FI leakage (liquid/mucus vs. stool only vs. liquid/mucus and stool) was not significantly associated with abnormalities on ARM. Both frequency of FI episodes ≥1 day/month and a large amount of leakage were associated with a higher Bristol stool form scale (p=0.002 and p=0.02, respectively). Low volitional contractile response was associated with both frequency of FI (p=0.02) and amount of leakage (p=0.03). Interestingly, paradoxical contraction of the external anal sphincter on EMG and prolonged balloon expulsion (≥60 seconds), which suggest dyssynergic defecation, were present in 44/101 (44%) and 22/101 (22%) patients, respectively. 58 of the 101 patients with FI also had UI: stress and urge UI were seen in 41 and 38 patients, respectively. Conclusion: Clinical characterization of the severity of FI, especially amount of leakage, is associated with pathophysiologic abnormalities found on ARM. An abnormally low volitional contractile response was associated with both frequency of fecal incontinence and amount of leakage. Some patients with FI had evidence of dyssynergic defecation which may suggest overflow incontinence and might suggest a different treatment plan. In some patients with FI, urinary incontinence is also associated with fecal incontinence.

Diagnosis of Hirschsprung’s Disease: an age‐related approach in children below or above one year

The aim of this study was to evaluate the effectiveness of a differential diagnostic approach to Hirshchsprung's Disease (HD) on the basis of age. Data on 185 consecutive children with suspected HD were subjected to an age-related diagnostic approach. The patients were divided into two groups according to age (A < 1 year; B > 1 year). Children in Group A had rectal suction biopsy (RSB) and contrast enema (CE), and in Group B anorectal manometry (ARM) was performed. Patients with a normal recto-anal inhibitory reflex (RAIR) underwent bowel disimpaction and medical treatment. Only selected cases in Group B underwent RSB and CE. In Group A (18 patients) CE showed a colonic transitional zone in three patients, whereas RSB led to the diagnosis of HD in nine. In Group B (167 patients) ARM was not possible in seven patients and it was normal in 140 (normal anal sphincter pressure: 83; hypertonia of the internal anal sphincter: 57). The RAIR was negative in 20 patients. RSB performed in 31 children in Group B confirmed HD in three patients. For patients with a neonatal onset of constipation RSB is the best diagnostic technique. Chronic constipation is rarely due to HD and ARM is a useful non-invasive screening tool.

Anal pressure in experimental diabetes

Diabetes mellitus is a metabolic endocrine disorder that affects many systems, the gastrointestinal system often being among the affected systems. This experimental study work was designed to demonstrate altered anal sphincter pressures in an experimental model of diabetes mellitus (DM). Male Wistar rats (mean weight = 250 g) were used and randomized in two groups (n = 10): CO = control and DM. DM was induced by administering a single dose of streptozotocin. Glycemic levels were measured at the start (time = 0) and end (time = 60) of the experiment and anorectal manometry at the end. DM rats presented a significant increase in glycemia at day 60 (DM = 407.14 +/- 73.76) as compared to the control group (time 0 = 175.7 +/- 18.62 and time 60 = 198.04 +/- 28.66). Anorectal manometry showed a significant decrease in anal pressure in the DM group at day 60 (DM = 34.2 +/- 4.97) as compared to the CO group at the same time (CO = 67.4 +/- 2.06), with P < 0.01 and P < 0.001 (Student's t test). The results suggest that DM, due to the high glycemic levels, lead to alterations such as anal sphincter hypotony, which may cause complications such as fecal incontinence.

Influence of Intravenous Propofol Sedation on Anorectal Manometry in Healthy Adults

BackgroundWe aimed to determine whether conscious sedation by propofol could affect anorectal manometry. MethodsEighteen healthy subjects underwent anorectal manometry at baseline and during conscious sedation by propofol. sedation levels were monitored by auditory-evoked potentials. ResultsAll subjects showed a normal rectoanal inhibitory reflex (RAIR) before conscious sedation. During conscious sedation, the resting anal sphincter pressure was significantly lower compared with that before conscious sedation (15±2 versus 42±4mm Hg, P<0.001). RAIR was present in all subjects during conscious sedation. There was no difference in threshold volume inducing RAIR before and during conscious sedation (P=NS). The level of auditory-evoked potentials did not correlate well with any of the anorectal parameters. ConclusionsPropofol significantly reduces the resting anal sphincter pressure without affecting RAIR. The inability to obtain useful data in anorectal sensation and sphincter pressure might limit the utility of propofol as a sedation agent for performing anorectal manometry.

S1264 Anal Electrical Stimulation Increases Anal Sphincter Pressure in Healthy Subjects

ation of reduced pain thresholds and a history of frequent visceral pain (Rome III questionnaire: question 42). Conclusion: In this patient population, IBS with or without painpredominance as diagnosed by Rome III criteria was not associated with VH as defined by reduced pain thresholds during rectal barostat distension. These findings suggest that 1) Rome III criteria might identify different patients than the former Rome II criteria; and/or that 2) the contribution of VH to the pathogenesis of pain in IBS may be smaller than hitherto assumed. Indeed, the latter hypothesis is supported by a recent study detecting VH in only 21% of IBS (Rome II) patients [2]. Provided our observations are confirmed in a larger trial including both healthy and specific disease control subjects, the pathogenic role and diagnostic value of VH in IBS need be re-considered. 1. Bouin et al. Gastroenterology 2002;122:1771-1777 2. Camilleri et al. Clin Gastroenterol Hepatol 2008;6:772-781

Clinical trial: effects of botulinum toxin on levator ani syndrome – a double‐blind, placebo‐controlled study

Levator ani syndrome is characterized by anorectal discomfort/pain, treatment of which is unsatisfactory. We hypothesized that Botulinum toxin relieves spasm and improves symptoms. To perform a randomized, placebo-controlled, crossover study to examine the efficacy and safety of botulinum toxin in patients with levator ani syndrome. Twelve patients with levator ani syndrome (>or=1 year) received anal intra sphincteric injections of 100 units of botulinum toxin A and placebo at 90-day intervals using EMG guidance. Daily frequency, severity, duration and intensity of pain (VAS) were recorded. Anorectal manometry, balloon expulsion and pudendal nerve latency tests were performed to examine the physiological changes and adverse effects. Seven patients (male/female = 4/3) completed the study and three had incomplete data, but all 10 underwent in an ITT analysis; two others dropped out. After administration of botulinum toxin, the mean frequency, intensity and duration of pain were unchanged (P = 0.31) compared with baseline. The 90-day mean VAS pain score was 6.79 +/- 0.27 vs. baseline score of 7.08 +/- 0.29 (P = 0.25). Anal sphincter pressures, rectal sensory thresholds, pudendal nerve latency and balloon expulsion times were unchanged after drug or placebo administration. Injection of botulinum toxin into anal sphincter is safe, but it does not improve anorectal pain in levator ani syndrome.

Investigation of the role of adrenergic and non‐nitrergic, non‐adrenergic neurotransmission in the sheep isolated internal anal sphincter

Nitric oxide is widely established as an important neurotransmitter in the control of anal sphincter tone; although, a number of other transmitters have also been tentatively implicated. Whilst alpha-adrenoceptor antagonists reduce anal sphincter pressure in man, the role of noradrenaline as a possible transmitter is poorly characterised. We have investigated the contribution of these transmitters to neurogenic relaxations, and evaluated the possible role of a non-nitrergic, non-adrenergic transmitter. The magnitude and duration of neurogenic responses were examined by measuring responses to electrical field stimulation (EFS) in segments of sheep internal anal sphincter following the development of spontaneous myogenic tone. Neurogenic relaxations induced by EFS were significantly reduced in the presence of N(G)-nitro-L-arginine methyl ester (L-NAME) suggesting major involvement of nitric oxide as a neurotransmitter. The duration of neurogenic relaxations was inversely related to the frequency of EFS, with contractile responses often manifest at higher frequencies. The duration of relaxations at high frequencies of EFS was increased by bretylium (adrenergic neurone blocker) and prazosin (alpha(1)-adrenoceptor antagonist). At higher frequencies of EFS, 60% of preparations also produced a residual non-nitrergic, non-adrenergic, apamin-sensitive relaxation which was unaffected by vasoactive intestinal polypeptide (VIP) and inhibitors of purinergic responses [suramin, pyridoxal-phosphate-6-azophenyl 2',4' disulfonic acid (PPADS) and alpha,beta-methylene adenosine triphosphate (ATP)]. However, MRS2179 (P2Y(1) receptor antagonist) showed a modest inhibitory effect. We conclude that endogenous noradrenaline acts via postjunctional alpha(1)-adrenoceptors to antagonize neurogenic relaxations that are largely mediated by nitric oxide. Our results indicate the involvement of a non-nitrergic, non-adrenergic, apamin-sensitive transmitter which is inhibited by MRS2179, suggesting a possible role for purines.

A Balloon-Tipped Catheter for Measuring Urethral Pressures

Background: Better methods are needed for recording urethral function for complex urologie problems involving the bladder, urethra, and pelvic floor.Objective: To evaluate a balloon catheter for recording urethral pressure and function using bench-top testing and evaluation in an animal model.Methods: Balloon pressure-recording methods included slightly inflating the balloon with water and placing the pressure transducer on the distal end of the catheter. For bench-top testing, manual procedures and a silastic tube with a restriction were used. In 3 anesthetized dogs, pressure recorded from the skeletal urethral sphincter was induced with electrical stimulation of the sphincter. Anal sphincter pressure was also recorded.Results: Bench-top testing showed good pressure recordings, including a confined peak at the tube restriction. Animal tests showed urethral pressure records with rapid responses when electrical stimulation was applied. Peak pressure at the urethral skeletal sphincter was 55.7 ± 15 cmH20, which was significantly higher than the peak pressure recorded 2 cm distally in the proximal urethra (3.3 ± 2.3 cmH20). Peak anal pressures were smaller and unchanged for the 2 stimulations.Conclusions: Balloon-pressure recordings showed rapid responses that were adequate for the tests conducted. In the animal model, high-pressure contractions specific to the skeletal urethral sphincter were shown. Balloon-tipped catheters warrant further investigation and may have applications for the evaluation of detrusor-sphincter dyssynergia after spinal cord injury or for stress urinary incontinence.

Rectal prolapse associated with extensive anorectal condyloma acuminata

Sir, Complete rectal prolapse (full-thickness and circumferential intussusception of the entire rectal wall through the anal canal) is not a common condition.[1] Furthermore, the presence of anorectal giant condyloma acuminata (Con A; a sexually transmitted disease caused by human papilloma viruses [HPV]) has been rarely reported in association with or as the probable cause of rectal prolapse.[2] We report a patient with extensive longstanding anorectal Con A with recurrent rectal prolapse that became irreducible and required urgent surgery for reduction and perianal and abdominal rectopexy. A 51-year-old woman, mother of six children, presented with longstanding history of extensive perineal and vaginal Con A for 15 years, which has been proved by microbiology, immunology, and histological examination to be due to human papilloma virus (HPV) with occasional concomitant candidal infection. She received different regimens of local and systemic medical treatment for the Con A and candida, but the perianal Con A persisted. She had a history of recurrent mild rectal bleeding that became heavier in the last year and also reported tensemus and occasional reducible anal mass on straining. She developed complete rectal prolapse on straining [Figure 1]. Under general anesthesia, the edematous rectum could only be reduced through lower abdominal laparotomy. The grossly patulous anus was repaired by using Thiersch's procedure, and then rectosigmoidopexy was done. The perianal condyloma was fulgurated by diathermy. The tissue histology was consistent with Con A with no malignancy. Figure 1 Rectal prolapse with inflammation, thickening, edematous, ulcerating, and anal condyloma acuminata The precise cause of rectal prolapse is not fully defined. However, a number of associated abnormalities and conditions have been described. Nearly 50% of rectal prolapse is caused by longstanding constipation with chronic straining. Other causes include increased intraabdominal pressure, a deep pouch of Douglas, weakness of the pelvic floor, decreased resting anal sphincter pressure, neurological disorders, and some parasitic infections (amebiasis and schistosomiasis).[1] On the other hand, Con A (warts) is generally a sexually transmitted disease of adults caused by HPV usually type 6 and 11 double-stranded DNA viruses that replicate in squamous epithelial cells. It occurs mainly in genital and perianal areas (moist area) but rarely in the rectum. The lesion may progress into large papillomatous proliferations called condylomata gigantean or Buschke-Lowenstein tumor that penetrates deep into the underlying tissue, usually without metastatic potential.[3,4] This case report demonstrates some of the challenges in caring for patients with Con A and the consequences. The importance of aggressive extirpation therapy was not appreciated until very late in her course. The presence of anorectal giant Con A and the association with rectal prolapse is rarely recognized in the literature.

Effective methods of pelvic plexus nerve and bladder stimulation in anesthetized animal model

Urinary retention is a serious urological problem associated with spinal cord injuries (SCIs) and other pelvic disorders. Effective methods of pelvic nerve stimulation were investigated for this problem. Following anesthesia in five dogs, the bladder was surgically exposed. Bladder and anal sphincter pressures were recorded. Testing was first conducted with probe electrodes. Barb electrodes were then implanted with a needle near the pelvic plexus nerves and the bladder wall. We tested different electrode arrangements and stimulating parameters to induce bladder contractions without skeletal muscle stimulation. The pelvic plexus nerves near the bladder were identified, and the barb electrodes were effectively implanted. Stimulation with bipolar and bilateral electrodes induced pressures over 30 cmH(2)O without skeletal muscle activation. Common stimulation parameters were 40 pps, 400 microseconds pulse duration, and 15 to 25 mA stimulating current applied for 3 s. Effective electrode implantation methods were shown. Also identified were electrode arrangements and stimulating parameters that induced strong bladder contractions without skeletal muscle activation. However, voiding studies were not conducted. Further studies with barb electrodes are warranted, and these methods may have applications for bladder stimulation following SCI.

Preliminary evaluation of anorectal manometry in diagnosing Hirschsprung’s disease in neonates

The aim of this paper was to assess the clinical value of anorectal manometry (ARMM) in the diagnosing of Hirschsprung's disease (HD) in neonates. From January 2003 to June 2005, 75 patients in whom HD was clinically suspected were analyzed. ARMM was performed using a desk, high rate gastrointestinal dynamic detection system and the results were compared with barium enema and rectal suction biopsy. Based on rectal suction biopsies in 52 of 75 patients, the positive, false positive, negative, and false negative rates of ARMM in the diagnosis of HD in neonates were found to be 92.3, 1.9, 1.9, and 3.8%, respectively. Forty-three of 75 patients were diagnosed with HD by both ARMM and barium enema and the diagnoses were validated by pathologic results. The diagnosis of HD was excluded in 18 patients in whom HD was clinically suspected, but in whom the results of ARMM and barium enema were normal. Twelve patients who had ARMM results consistent with HD and a negative barium enema, had serial ARMM performed; a rectoanal inhibitory reflex (RAIR) was elicited in four patients, thereby excluding HD and the remaining eight patients were diagnosed with HD by review of barium enema and pathologic results. One of two patients with a positive barium enema for HD, but an ARMM showing the presence of RAIR was excluded by pathologic results and the other patient was lost to follow-up. The diagnostic accuracies of ARMM and barium enema for HD in neonates were 93.3 and 86.7%, respectively. There was no difference in rectal resting pressure and anal rhythmic wave frequency between neonates with HD and healthy neonates, but neonates with HD had higher anal sphincter pressures than healthy neonates (P=0.0074). ARMM is a simple, safe, and non-invasive method with high specificity for the diagnosis of HD in neonates.

Fecal Incontinence

Purpose: Fecal incontinence (FI) has been receiving increased attention from health care providers. Better characterization of patients is needed to improve understanding and treatment. Differentiation of patients based on frequency and severity of fecal incontinence includes major incontinence (MajorI) representing frequent (at least one episode per week) occurrence of urge or passive incontinence and minor incontinence (minorI) representing occasional leakage. Some patients with fecal incontinence may also have concomitant constipation and urinary incontinence. Aim: To characterize fecal incontinence (FI) using both symptoms and motility testing. Methods: Patients referred to the Temple University GI Motility Laboratory for anorectal manometry between January to May 2008 filled out a questionnaire using validated questions and underwent anorectal manometry (ARM), anal electromyography (EMG), and balloon expulsion testing (BET). Results: Thirty-nine patients with FI were evaluated; fifteen patients had MajorI and twenty-four had minorI. Patients with MajorI reported 34 ± 12 stools per week compared to only 7 ± 2 for patients with minorI (P= 0.01). Constipation was present in 5/15 (33%) MajorI patients but in 18/23 (78%) minorI patients (P= 0.01). MajorI patients described their stool as 5.1 ± 0.6 on the Bristol stool form scale compared to 3.4 ± 0.5 for minor I (P= 0.05). Urinary incontinence was present among 9/15 (60%) MajorI patients and 6/24 (38%) minorI patients (P= 0.20). Of the 39 patients with FI, physiologic abnormalities included low resting anal sphincter pressure (12 patients), low volitional contractile response of the external anal sphincter (16 patients), elevated threshold for first sensation (18 patients), paradoxical EMG response while bearing down (17 patients), and prolonged balloon expulsion (16 patients). Compared to patients with minorI, patients with MajorI tended to have lower resting basal anal pressure (63 ± 9 vs 68 ± 4 mmHg; P= 0.59) and volitional contractile response (57 ± 15 vs 73 ± 11 mmHg; P= 0.39), but higher threshold for first sensation (29 ± 3 vs 25 ± 2 ml; P= 0.10), desire to defecate (129 ± 33 vs 87 ± 8 ml; P= 0.41), and maximum tolerable volume (167 ± 20 vs 142 ± 15 ml; P= 0.32). Evidence for dyssynergic defecation was present among 5/15 (33%) patients with MajorI and 11/24 (46%) patients with minorI (P= 0.52). Conclusion: Patients with major incontinence reported more frequent bowel movements and looser stools than those with minor incontinence. Interestingly, patients with minor incontinence also frequently reported constipation. Careful symptom evaluation in patients with fecal incontinence complements anal manometry in characterizing patients with fecal incontinence.

Effects of Caffeine on Anorectal Manometric Findings

This study was designed to evaluate the effects of caffeine on anorectal function by anorectal manometry. Ten healthy subjects were studied. They drank 200 ml of water and later 200 ml of a solution that contained caffeine 3.5 mg/kg body weight. The anorectal manometric study was divided into three periods: basal, water, and caffeine; each period lasted 45 minutes. After the ingestion of water, the basal anal sphincter pressure showed no change during the 45-minute recording, whereas after caffeine consumption the basal anal sphincter pressure increased at 10 minutes (P = 0.047) and 15 minutes (P = 0.037). The average basal anal sphincter pressure throughout the 45 minutes was significantly higher after caffeine ingestion than after water (P = 0.013). After caffeine intake, the maximum squeeze pressure increased significantly (P = 0.017) compared with the basal period. Both water and caffeine consumption caused a decrease in the rectal sensory threshold for the desire to defecate. Caffeine 3.5 mg/kg body weight in 200 ml of water resulted in stronger anal sphincter contractions both at basal period and during voluntary squeeze. The sensory threshold was also decreased, leading to an earlier desire to defecate. Caffeine consumption may result in an earlier desire to defecate, leading to defecation if the anal sphincter can relax voluntarily.