Anorectal Incontinence Research Articles

Prevención de la disfunción del suelo pélvico de origen obstétrico

AbstractMany researches have proved scientifically that the vaginal delivery is the main cause of the pelvic floor dysfunction, swing to the mechanical stress supported by the conjunctive, muscle and neurological tissue. This dysfunction may cause urinary, anorectal incontinence, constipation or pelvic prolapse to a greater or to a lesser degree. The elective caesarean reduce the risk of incontinence compared to the vaginal delivery, but pregnancy itself is considered us a risk factor because of the hormonal and mechanical modificationsSince caesarean is not the best solutions to prevent these dysfunctions, we consider that ther must be programs to prevent urinary incontinence, anorectal incontinence and prolapses problems during pregnancy, delivery and specially the postpartum period. To prevent all these dysfunctions, there must be programs about exercises for the pelvic floor muscles during pregnancy and postpartum period. Besides, in the postpartum period we need to take greater care over the hipopressive abdominal exercises designed by Caufriez

Anorectal Incontinence: Aetiology, Pathophysiology and Evaluation

Faecal incontinence is a complex problem, often of multifactorial origin. Although the condition is widely accepted as a problem in the elderly, it is now becoming apparent that much younger age groups are frequently affected. Its exact incidence is about 2% of the general population, while in other individuals, the prevalence has been reported to approach 60%. Despite the considerable advances that have been made the past decades in the evaluation of anorcctal incontinence, our understanding of it remains limited. A thorough history, good physical examination, and detailed anorectal physiological investigations can help the therapeutic decision-making algorithm. Complete functional and anatomical assessments of the anorectum, anal sphincters, and pelvic floor are mandatory in all patients with faecal incontinence to correctly identify the cause and type of incontinence and allow correct treatment. Anorectal manometry is used to establish the presence and extent of the weakness degree of the pelvic floor sphincter muscles, allowing an objective measure of resting and squeeze pressure. Anal endosonography is a very valuable tool in planning restorative surgery or in assessing results after sphincter repair. Because electromyography may detect functional abnormalities, the two techniques are complementary and not mutually exclusive. Determining the most appropriate tests will largely depend on the patient's history and symptoms and can vary for each patient.

Anal endosonography in patients with anorectal symptoms after haemorrhoidectomy.

Anorectal symptoms after haemorrhoidectomy are common and treatment is often empirical. Because of this, an audit was carried out of the value of anal endosonography in patients with anorectal symptoms after haemorrhoidectomy. Between May 1993 and February 1997, 16 patients (ten men and six women of median age 56 (range 35-77) years) were investigated by anal endosonography for anorectal symptoms after haemorrhoidectomy which involved anorectal incontinence (n = 10), anal pain (n = 4) and obstructive defaecation (n = 2). The findings were compared with those in a matched group of asymptomatic patients after haemorroidectomy. Anal endosonography demonstrated an abnormality in 12 symptomatic patients. Of the ten patients with anorectal incontinence, endosonography showed an internal anal sphincter defect (n = 5), a combined sphincter defect (n = 2) and an isolated external anal sphincter defect (n = 1). Normal appearances were seen in all asymptomatic patients. The endosonographic abnormalities of the four patients with anal pain included internal anal sphincter defect (n = 1), extrinsic mass (n = 1), and intersphincteric abscess (n = 1). One of the two patients with obstructive defaecation had an isolated external anal sphincter defect on endosonography. These results show a high yield of endosonographic abnormalities in patients who experience symptoms after haemorrhoidectomy. In particular, occult sphincter injury as a cause of incontinence in these patients can frequently be demonstrated.

Urinary incontinence and vesicourethral dysfunction in pediatric surgical conditions.

The most common cause for urinary incontinence in children with pediatric surgical conditions of the pelvic region and perineum is lower urinary tract dysfunction caused by concomitant sacral agenesis, especially in children with anorectal malformations. Another common cause is iatrogenic pelvic nerve damage secondary to reconstructive surgery. Moreover, an intrinsically altered pelvic floor anatomy as seen in some cases of complex cloacas, or disruption of pelvic floor muscles with consecutive loss of supportive structures, as in sacrococcygeal teratoma, should also be taken into consideration. It is important to understand that the causes of urinary incontinence in these children are not isolated problems concerning only the urinary tract. They may have the same negative impact on anorectal function as they have on the bladder and urethral sphincter. Therefore, children with pediatric surgical conditions of the pelvic and perineal region often will present with a combination of both fecal incontinence caused by anorectal dysfunction and urinary incontinence caused by vesicourethral dysfunction. The additional morbidity caused by urinary incontinence may have an enormous impact on the patient's life and well being, not only with regard to physical disability, but also in terms of emotional problems, social handicap, and socioeconomic burden. It is obvious that a patient's quality of life will be significantly reduced if he or she suffers from both fecal and urinary incontinence. Therefore, an integrated approach to the management of both vesicourethral and anorectal dysfunction should be developed to achieve the optimum care for these children.

The value of posterior levator repair in the treatment of anorectal incontinence due to rectal prolapse--a clinical and manometric study.

When treating a complete rectal prolapse, the most important objective is elimination of the prolapse. In addition, restoration of sufficient anorectal continence is extremely important for the patients. We examined the value of posterior levator repair with respect to stabilization of the pelvic floor and to improvement in anorectal incontinence. In patients with disabling anorectal incontinence, a posterior levatorplasty can be concomitantly performed during operative removal of the prolapse. To facilitate evaluation of the operative results, we implemented a scoring system to judge the patients' subjective symptoms of incontinence; in addition, we performed manometric measurements of resting and squeezing pressures of the anal sphincter to objectify the anorectal incontinence. From 1991 to 1997, 84 patients (mean age 65+/-10 years, 38-91 years; 79 women, 5 men) with complete rectal prolapse and severe incontinence were operatively treated; corresponding follow-ups were done. The following procedures were performed: Frykmann-Goldberg, 28 patients; Wells, 18 patients; Ripstein, 22 patients; and perineal proctectomy, 16 patients. Incontinence for liquid and solid stools was present in all of these patients. Posterior levatorplasty was implemented in 38 patients, and in this group we found significantly better postoperative results, both clinically and in the manometric measurements. Continence was improved by 84% in the group with levatorplasty, but improvement was only 67% in the other group (P<0.05). The incontinence score decreased significantly in the group with levatorplasty (preoperative 16.4+/-3.1, postoperative 9.3+/-4.5, P<0.05, vs the other group with preoperative 15.6+/-4.2, postoperative 11.5+/-5.1). Manometric observations in the group with levatorplasty demonstrated 55% improvement in resting pressure (preoperative 29+/-17 cm H2O, postoperative 45+/-21 cm H2O, P<0.05) and 40% improvement in squeezing pressure (preoperative 61+/-25 cm H2O, postoperative 85+/-31 cm H2O, P<0.05). In the group without levatorplasty, resting and squeezing pressure improved only by 20% (resting pressure: preoperative 32+/-16 cm H2O, postoperative 38+/-18 cm H2O; squeezing pressure: preoperative 64+/-29 cm H2O, postoperative 75+/-26 cm H2O). Posterior levatorplasty is an easy and efficient operative procedure which facilitates an improvement in anorectal continence. There are no apparent disadvantages. For this reason, levatorplasty can be part of operative procedures implemented in the treatment of a complete rectal prolapse accompanied by disabling anorectal incontinence.

Long-term results of low anterior resection with intersphincteric anastomosis in carcinoma of the lower one-third of the rectum

Between 1985 and 1996, 190 patients underwent a low anterior rectal resection with coloanal anastomosis for adenocarcinoma of the lower one-third of the rectum. This article reports on 31 (17 males) of these patients with a very low localization of the tumor (distal tumor margin 1.3 +/- 0.9 cm above the dentate line). If the function of the sphincter was acceptable and we could exclude tumor infiltration into the sphincter through endosonography, we relocated the resection plane distally into the intersphincteric region to attain an acceptable margin of safety. In all of these cases, it was impossible for us to perform the usual surgical procedure of a mechanical anastomosis by means of a circular stapler. After intersphincteric rectal resection, the anastomosis was handsewn, using interrupted sutures from the perineal approach, 2.5 to 3 cm above the anal verge, implementing Parks' retractor. A protective stoma was performed in all cases. All data were documented prospectively. Postoperative mortality was 0 percent. Postoperatively, none of the patients showed an indication for relaparotomy. The leakage rate was 48 percent. Only 16 percent later needed additional surgery for anastomotic strictures or for rectovaginal fistulas. Long-term observations showed that the anastomosis healed well in 27 patients (87.1 percent). Four patients (12.9 percent) decided to have a terminal colostomy performed (anastomotic stricture, 3 patients; anorectal incontinence, 1 patient). During the follow-up period of 6.8 +/- 3.7 years, six patients (19.4 percent) developed a tumor progression (9.7 percent local recurrences and 12.9 percent distant spread). The five-year survival rate was 79 percent (Dukes A, 100 percent (n = 18); Dukes B, 67 percent (n = 4); and Dukes C, 44 percent (n = 9)). Continence: One-third of patients developed anorectal incontinence for liquid (29.6 percent) or solid stool (3.7 percent). Average stool frequency was 3.3 times per day. Resting pressure decreased significantly by 29 percent (preoperative, 105 +/- 37 cm H2O and postoperative, 75 +/- 19 cm H2O; P < 0.05), whereas squeeze pressure did not change. In selected patients with tumors close to the dentate line, an intersphincteric resection of the rectum may help to avoid an abdominoperineal excision of the rectum with a terminal stoma, without any curtailment of oncologic standards. A protective stoma for three months is advantageous.

Surgery of anorectal incontinence

Faecal incontinence is a far more common problem than is generally appreciated and it is not confined just to elderly people. The prevalence rate among individuals aged above 15 years has been reported to be 4.3 per 1000 population, 1 but this figure is likely to be a considerable underestimate. Incontinence is not a subject that patients and doctors are comfortable discussing, so it receives little media exposure. Hence, there is ignorance about the considerable progress that has been made in the understanding of anorectal physiology, which has paved the way for improvements in therapy. Since a colostomy is still commonly perceived to be the only procedure available for this distressing disorder, only a small proportion of patients are referred to appropriate specialist units.

Fecal Incontinence in Women

Pelvic floor disorders are common in women. Most gynecologists are well versed in the management of urinary incontinence and uterovaginal prolapse; however, knowledge of disorders involving the anorectum is often lacking. This review will discuss the issue of anorectal incontinence in women, attempt to provide a logical outline for evaluation and treatment, and offer potential methods of prevention.

Resolution of anorectal incontinence in herpes proctitis confirmed by anorectal manometry

Herpes simplex virus has been known to affect anorectal motor function when the vaginal and anorectal area are infected by this virus.1-3 We describe the resolution of sacral nerve dysfunction manifested primarily by fecal incontinence in a patient with anogenital herpes infection, as documented by serial anorectal manometry recordings.

Surgical management of anorectal incontinence due to internal anal sphincter deficiency

The aetiology, surgical management and outcome in 15 patients with anorectal incontinence due to internal and sphincter (IAS) deficiency as a result of previous anal surgery (n = 14) or penetrating trauma (n = 1) was studied. The degree of anorectal incontinence was scored by the Cleveland Clinic system; median score was 14 (range 11-16) before surgery. In all patients the anal sphincter mechanism was assessed by endoanal ultrasonography. Thirteen of the 15 patients underwent either rotation (n = 5), island (n = 5) or advancement (n = 3) anoplasty to correct the contour defect in the anal canal. In the remaining two patients direct IAS repair was performed. Four of the 13 patients who underwent anoplasty developed wound breakdown as the result of infection (n = 3) or inadvertent suture removal (n = 1). A defunctioning stoma was required in three of these patients but all of these have been closed. At median follow-up of 34 (range 6-72) months, all patients who underwent anoplasty have normal defaecatory control and a median continence score of 2 (range 0-4). Direct IAS repair produced no symptomatic improvement in either patient. These results suggest that anoplasty deserves further evaluation in the treatment of anorectal incontinence due to discrete IAS defects, but that the place of IAS repair remains uncertain.

Surgical management of anorectal incontinence due to internal anal sphincter deficiency

Surgical management of anorectal incontinence due to internal anal sphincter deficiency

Biofeedback

The overall success rate of biofeedback in ano-rectal incontinence and chronic constipation is reported to be 50-92% and 35-90%, respectively. In patients with neurogenic incontinence, the results are poor. Biofeedback, in case of outlet obstruction, seems only to be useful if there is paradoxical contraction of the external anal sphincter and/or the puborectalis muscle during straining (anismus). Further investigations to select patients who would profit from this therapy are, therefore, necessary.

Risks of Anal Incontinence From Subsequent Vaginal Delivery After a Complete Obstetric Anal Sphincter Tear

Objective To assess the influence of various risk factors on long term anal incontinence in women with a complete obstetric tear of the anal sphincter. Design Postal questionnaire. Setting Department of Gynecology and Obstetrics, Aarhus University Hospital, Denmark. Subjects 152 women with complete obstetric tear of the anal sphincter. Main outcome measures Occurrence and duration of anal incontinence in relation to any delivery. Results 56 of 121 respondents had experienced a subsequent vaginal delivery; 23 (41%) of these had had transient anorectal incontinence directly after the complete tear and four (7%) had permanent anorectal incontinence. In the 23 women with transient anorectal incontinence directly after the complete tear, 9 (39%; 95% CI 19%-59%) developed anorectal incontinence after the next delivery, and this was permanent in four (17–4%; 95% CI 2%–33%). In the 29 women without anorectal incontinence after complete tear, two had transient incontinence of flatus but for less than 14 days after the next delivery. Conclusions Transient anal incontinence after a complete tear is a predictor of anal incontinence after subsequent vaginal delivery. The major long term problem in our study of premenopausal women was incontinence of flatus. This possibility should be discussed with the women when a further pregnancy is planned.

Risks of anal incontinence from subsequent vaginal delivery after a complete obstetric anal sphincter tear.

To assess the influence of various risk factors on long term anal incontinence in women with a complete obstetric tear of the anal sphincter. Postal questionnaire. Department of Gynecology and Obstetrics, Aarhus University Hospital, Denmark. 152 women with complete obstetric tear of the anal sphincter. Occurrence and duration of anal incontinence in relation to any delivery. 56 of 121 respondents had experienced a subsequent vaginal delivery; 23 (41%) of these had had transient anorectal incontinence directly after the complete tear and four (7%) had permanent anorectal incontinence. In the 23 women with transient anorectal incontinence directly after the complete tear, 9 (39%; 95% CI 19%-59%) developed anorectal incontinence after the next delivery, and this was permanent in four (17.4%; 95% CI 2%-33%). In the 29 women without anorectal incontinence after complete tear, two had transient incontinence of flatus but for less than 14 days after the next delivery. Transient anal incontinence after a complete tear is a predictor of anal incontinence after subsequent vaginal delivery. The major long term problem in our study of premenopausal women was incontinence of flatus. This possibility should be discussed with the women when a further pregnancy is planned.

The anal continence plug: a disposable device for patients with anorectal incontinence

Anorectal incontinence is most commonly found in the elderly, but colorectal surgeons now see an increasing number of younger patients with this condition. Although medical and surgical treatments are available, a proportion of patients remain refractory to therapy. We investigated the efficacy of three designs of anal continence plug. 8 women and 2 men (mean age, 52 years) who were incontinent to both liquid and solid stool tested each plug for three consecutive weeks. 1 patient withdrew from the study. The median weartime for the optimum plug design was 12 h, and there were no episodes of incontinence in 82% of the periods during which the plug was in place. Patients required a median of eleven plugs per week, and in 82% of cases insertion was as easy as with a suppository. Plugs may have a place in the management of patients with anorectal incontinence.

Percutaneous Electrical Stimulation for Ano-rectal Incontinence

Summary This paper reviews the scientific evidence to support the hypotheses that pelvic floor weakness may result from a pudendal neuropathy caused by entrapment or stretch injury during childbirth or excessive straining at defaecation and can result in stress or ano-rectal incontinence. Such patients demonstrate sensory and motor deficits and pose a rehabilitation problem for physiotherapists and doctors alike. The role of current physiotherapeutic practice is questioned in the light of this new evidence for the existence of pelvic floor weakness of neurogenic origin. The results of a pilot study into the use of percutaneous electrical stimulation as a method of conservative management of patients with proven pudendal neuropathy is described, undertaken jointly between the department of surgery and school of physiotherapy at Withington Hospital. The paper suggests further research which may be needed to enable therapists to select the most appropriate method of treatment for each patient.

Doppelbelichtungs-Defäkographie nach perinealer Sphinkterplastik

A new diagnostic method is presented as "Double-Exposure Defaecography". Its advantage is the reliable evaluation of functional parameters of defaecography without the aid of obligatory auxiliary lines in relation to the drawing of the relevant skeletal parts. Less display and effort are needed than in cineradiography. The so called pinching test allows functional, quantitative examination of musculus puborectalis. The evaluation is performed on double-exposed x-ray films. Besides a group of patients suffering from anorectal incontinence and difficulties in defaecation (n = 42), a group of patients (n = 21) with smooth-muscular perineal sphincter replacement was controlled by double-exposure defaecography. This fairly new method of surgery restores continence in 80% of the cases.

Ultrastructural changes in internal anal sphincter in neurogenic faecal incontinence.

The ultrastructural features of the internal anal sphincter (IAS) muscle were studied in biopsies from five patients with neurogenic anorectal incontinence and six control subjects undergoing anorectal excision for cancer, or for inflammatory bowel disease. In the patients with idiopathic neurogenic anorectal incontinence the internal anal sphincter showed loss of smooth muscle cells, disruption of the normal relationships of the remaining cells, stretching of elastic tissue, and increased collagen fibril content. These ultrastructural changes in the morphology of the internal anal sphincter, although probably not the primary cause of faecal incontinence, have functional relevance in the clinical syndrome, as shown by the reduction in resting anal canal pressure found in some patients with this syndrome.

Anorectal incontinence: Diagnosis and treatment

In correcting anorectal incontinence, the analysis of all known factors responsible for a lack of function is mandatory. Besides anamnestic and clinical data, manometric investigation is especially helpful. Continence may be improved by conservative measures (biofeedback training, muscle training, and drugs). The indication for surgical procedures depends on clinical and manometric findings: missed portions of the sphincteric muscle complex are reintegrated with a repull-through procedure. In some cases, Kottmeier's levatorplasty or a modification of it has led to some improvement of continence. Whenever a call to stool was present, gracilis transposition has markedly improved anorectal function in 22 of 27 operated patients. Free transplantation of palmaris longus muscle has not proven to be of functional advantage. Doubling the circular colonic musculature and an S-shaped anoplasty at the time of the primary pull-through procedure may lead to continence in the future.

Relation between perineal descent and pudendal nerve damage in idiopathic faecal incontinence.

In 60 patients with idiopathic anorectal incontinence, without neurological disease, there was a significant relationship, shown by regression analysis, between the pudendal nerve terminal motor latency and the extent of perineal descent during straining (r 0.59; p less than 0.001), and the plane of the perineum on straining (r -0.61; p less than 0.001). These data are consistent with the suggestion that perineal descent can lead to stretch-induced damage to the perineal nerves in this condition.