External Anal Sphincter Defects Research Articles

One-stage implant in sacral neuromodulation for faecal incontinence - short-term outcome from a prospective study.

Sacral neuromodulation (SNM) is approved for the treatment of faecal incontinence (FI) in a two-stage technique. With standardized implantation, approximately 90% of patients undergo successful Stage I operation and proceed to a permanent implant (Stage II). The aim of this work was to explore the feasibility of SNM as a one-stage procedure and report the 24-week efficacy. This study included patients diagnosed with idiopathic FI or FI due to an external anal sphincter defect ≤160° and one or more episodes of FI per week despite maximal conservative therapy. Patients were offered a one-stage procedure if a motor response of the external anal sphincter was achieved in three or more poles with at least one at ≤1.5 mA at lead placement. Patients were followed for 24 weeks. Their evaluation included the Wexner/St Mark's Incontinence Score, Faecal Incontinence Quality of Life score (FIQoL), a visual analogue scale (VAS) for assessing patient satisfaction and a bowel habit diary. Seventy-three patients with a median age of 60 years (interquartile range 50-69 years) completed this prospective study. Episodes of FI were significantly reduced at the 24-week follow-up, from 13 (8-23) at baseline to 2 (0-5) (p-value = 0002). A ≥50% reduction in the number of FI episodes was achieved in 92% of participants. The Wexner score improved significantly from 16 (14-17) at baseline to 9 (5-13) (p-value < 0.001), and the St Mark's score improved significantly from 18 (16-20) to 11 (7-16) (p-value < 0.001). All domains in the FIQoL score and VAS for patient satisfaction improved significantly following the one-stage procedure. A one-stage implantation procedure is feasible in selected patients with FI, significantly improving continence, quality of life and patient satisfaction after 24 weeks of follow-up.

The Use of Sphinkeeper® In Faecal Incontinence

Introduction: Faecal Incontinence is a condition that can affect up to 20% of population during their lifetime with female predominance. Sacral Nerve Stimulation (SNS) has been recently shown to have significant benefits in mainly urge incontinence but this has left a large group of patients with passive incontinence without effective management options. The SphinKeeper® (SK) allows treatment of more sizeable defects in the internal or external anal sphincter. Preliminary series have shown some benefit of the procedure in treatment of faecal incontinence. Methods: A single-centre retrospective observational study of SphinKeeper® prostheses was conducted at St Helens and Knowsley NHS trust and we believe this to be one of the largest series of SphinKeeper® in the UK. SphinKeeper® restores sphincter function by using placement of self-expanding prostheses into the inter-sphincteric space. The operation involves implantation of 10 self-expanding sterile prostheses between the internal and the external sphincter, thus creating a third ring around the circumference of the anal canal. Results: Most patients were ASA 2 (n=10). 43% (6/14) patients had previous colorectal surgery – THD and mucopexy (n=3), anorectal fistula surgery (n=1), anterior resection of rectum (n=1) and pelvic floor repair (n=1). EUS was carried out in 6 patients and in all 6 cases identified internal or external anal sphincter defect (IAS n=1, EAS n=3, IAS and EAS n=2). No patient sustained intraoperative complications. 2 patients reattended within 48 hours post op due to severe post-operative pain and were discharged with analgesia. Subjective results were evaluated using Vaizey and Wexner scores and showed significant improvement 4/14 patients, partial improvement in 7/14 patients and no improvement in 3/14 patients. Discussion: Our study evaluated the short-term outcomes of the procedure in 14 patients who had SphinKeeper® surgery between May 2017 and August 2020. Patients who took part in our study had previous treatment for faecal incontinence by a variety of methods (both medical and surgical) and suffered from different types of FI (passive, urge, mixed, associated urinary incontinence). It was promising to see there was a clinically significant improvement in continence indicated by a decrease in Vaizey and Wexner scores (p=0.00377 and p=0.00334 respectively (Wilcoxon test)) with 11 patients improving in scores. It is reasonable to consider Sphinkeeper™ as a safe and minimally invasive surgical intervention to achieve some degree of positive improvement for patients suffering from faecal incontinence.

Diagnostic capabilities of transperineal ultrasound (TPUS) to evaluate anal sphincter defect post obstetric anal sphincter injury (OASIS)? A systematic review

IntroductionEndoanal ultrasound (3D-EAUS) is the gold standard imaging investigation for evaluating the anal sphincter; unfortunately, it is not universally available in most obstetric units. This study aims to appraise the ability of transperineal ultrasound (TPUS) compared with 3D-EAUS as the gold standard to identify anal sphincter defects after primary repair of OASIS.MethodsA systematic search of major databases to identify diagnostic accuracy of 3D-TPUS in evaluating anal sphincter defects. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were designed for this systematic review. The risk of bias and applicability concerns were assessed using the QUADAS-2 tool. Our eligibility criteria are patients with a history of primary repair of anal sphincter injuries (OASIS). They were followed up after the primary repair to detect the anal sphincter defect using 3D-TPUS vs. 3D-EAUS as a gold standard.ResultsTwo eligible observational studies were included and assessed for risk of bias using the QUADAS-2 tool and showed a low risk of bias and a low risk of concerns. 3D-TPUS had various sensitivity to detect external anal sphincter defects in two studies; meanwhile, the specificity was around 67–70%. For detecting the internal anal sphincter defects, 3D-TPUS had low sensitivity but high specificity (93–94%).Conclusion3D-TPUS had various sensitivity to detect external anal sphincter defects and low sensitivity to detect internal anal sphincter defects. On the other hand, 3D-TPUS had low specificity for detecting external anal sphincter defects and high specificity for detecting internal anal sphincter defects.

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

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

Validation of new ultrasound algorithm for estimating prevalence of anal sphincter trauma in a urogynecological population.

To estimate the prevalence of major perineal trauma in a urogynecological population, to test the predictive value of sonographic tear grading (Gillor algorithm) for anal incontinence (AI), AI bother score and St Mark's score, and to compare the predictive power of the Gillor algorithm with that of the residual-defect method. This was a retrospective study of 721 women attending a tertiary urogynecology unit between February 2019 and May 2021. All women underwent a standardized interview, including determination of St Mark's score and visual analog scale (VAS) bother score for AI, as well as exoanal (translabial) ultrasound with later offline analysis. Results were reported as the presence of a residual defect of the external anal sphincter (EAS), i.e. a discontinuity of ≥ 30° in ≥ 4/6 tomographic slices, and according to the Gillor algorithm (normal, Grade 3a, Grade 3b or Grade 3c/4). Mean age at assessment was 57 (range, 19-93) years and mean body mass index was 30 (range, 17-57) kg/m2 . Six hundred and thirty-six (88.2%) women were vaginally parous and 161 (22.3%) had undergone at least one forceps delivery. AI was reported by 186/721 (25.8%) women, with a median St Mark's score of 10 (interquartile range (IQR), 6-14) and a median VAS score of 6.3 (IQR, 3.9-10). EAS defects were detected in 261 (36.2%) women, with a residual defect diagnosed in 88 (12.2%). On sonographic grading according to the Gillor algorithm, we identified 532 (73.8%) women with a normal sphincter, 66 (9.2%) with Grade-3a tear, 87 (12.1%) with Grade-3b tear and 36 (5.0%) with Grade-3c/4 tear. In total, the Gillor algorithm classified 189 (26.2%) women as having suffered a major perineal tear. The two grading systems were in moderate agreement (κ, 0.537 (95% CI, 0.49-0.56); P < 0.001). There were weak, albeit significant, associations between EAS defects and measures of AI (P = 0.009 to P = 0.047), both for residual defect as well as the Gillor algorithm. Neither the Gillor algorithm nor the residual-defect method of quantifying sphincter trauma on imaging is clearly superior in terms of predicting AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

When to assess residual anal sphincter defect after OASI by ultrasound

ObjectivesObstetrical anal sphincter injuries (OASIS) are complications of vaginal delivery. Unrepaired anal sphincter after delivery increases the risk of anal incontinence. The aim of our study is to search for residual defect after OASI repair by 4D introital ultrasound (US). We hypothesised that imaging prior to hospital discharge would show the same number of defects as assessment at 3 months. Study designThis is a retrospective analysis of 138 patients with immediate repair after OASIS. Since 2009, we have been routinely inviting all our patients with OASIS to the perineal clinic for postoperative follow-up. We scheduled the first visit before discharge from hospital and followed up with a second visit after three months. During both visits, patients underwent transperineal 4D ultrasound examination. We provided examination while at rest and during contraction; volumes were saved for further evaluation. ResultsEighty-one patients (58.7%) completed both exams and were included in the analysis. Residual external anal sphincter defect was found in 17.3% at the first visit versus 13.6% at the second (delayed) visit. We were not able to assess the sphincter in 9.9% at early versus none in the delayed examination. In 9.9%, the residual defect was not confirmed by the second examination, and in 4.9% the residual defect was missed by the first examination. ConclusionsIn conclusion, we have found that a 3 month scan yields a smaller number of defects than a scan before discharge.

3T external phased-array magnetic resonance imaging in detection of obstetric anal sphincter lesions: a pilot study.

Three-dimensional endoanal ultrasound (3D EAUS) has been the gold standard for detecting anal sphincter lesions in patients with a history of obstetric anal sphincter injury (OASI). Advances in imaging technologies have facilitated the detection of these lesions with external phased-array magnetic resonance imaging (MRI), which could offer an alternative imaging modality for the diagnosis of residual OASI (ROASI) in centers where 3D EAUS imaging is not available. To compare two diagnostic modalities: the 3D EAUS and 3T external phased-array MRI in the detection of residual anal sphincter lesions. A total of 24 women with a history of OASI were imaged with both 3D EAUS and 3T external phased-array MRI after primary repair of the injury. Intraclass correlation (ICC) and interrater reliability (IRR) values were calculated for the grade and circumference of the sphincter lesion. Sphincter lesions were graded according to the Sultan classification. There was an almost perfect agreement between 3D EAUS and 3T external phased-array MRI in determining the extent of the sphincter lesions according to the Sultan classification (κ = 0.881; P < 0.001) and the circumference of the external anal sphincter defects, measured in degrees (κ = 0.896; P < 0.001). The results of this study indicate that 3T external phased-array MRI and 3D EAUS yield comparable results in the diagnosis of ROASI. These findings suggest that 3T external phased-array MRI could serve as an alternative diagnostic modality to 3D EAUS in the diagnosis of ROASI.

Multimodal Management of Fecal Incontinence Focused on Sphincteroplasty: Long-Term Outcomes from a Single Center Case Series.

The management of patients with fecal incontinence and an external anal sphincter (EAS) defect remains controversial. A retrospective series of overlapping anal sphincteroplasties performed between 1985–2013 from a single center, supplemented by selective puborectalis plication and internal anal sphincter repair is presented. Patients were clinically followed along with anorectal manometry, continence scoring (Cleveland Clinic Incontinence Score—CCS) and patient satisfaction scales. Patients with a suboptimal outcome were managed with combinations of biofeedback therapy (BFT), peripheral tibial nerve stimulation (PTNS), sacral nerve stimulation (SNS) or repeat sphincteroplasty. There were 120 anterior sphincter repairs with 90 (75%) levatorplasties and 84 (70%) IAS repairs. Over a median follow-up of 120 months (IQR 60–173.7 months) there were significant improvements in the recorded CCIS values (90.8% with a preoperative CCIS > 15 vs. 2.5% postoperatively; p < 0.001). There were 42 patients who required ancillary treatment with four repeat sphincteroplasties, 35 patients undergoing biofeedback therapy, 10 patients treated with PTNS and three managed with SNS implants with an ultimate good functional outcome in 92.9% of cases. No difference was noted in ultimate functional outcome between those treated with sphincteroplasty alone compared with those who needed ancillary treatments (97.1% vs. 85.7%, respectively). Overall, 93.3% considered the outcome as either good or excellent. Long-term functional outcomes of an overlapping sphincteroplasty are good. If the initial outcome is suboptimal, response to ancillary treatments remains good and patients are not compromised by a first-up uncomplicated sphincter repair.

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

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

A prospective trial of the THD SphinKeeper® for faecal incontinence.

THD SphinKeeper® is an emerging surgical technique for faecal incontinence (FI). The safety, indications and efficacy of the procedure are still being investigated. The aim of this study is to present the first experience of SphinKeeper® in Australia. This was a prospective single-centre observational study of patients undergoing SphinKeeper® implantation between February 2018 and September 2019. Baseline demographics, intraoperative and postoperative complications, Cleveland Clinic Faecal Incontinence Score, St Mark's Incontinence Score, Faecal Incontinence Quality of Life score (FIQOL), anorectal manometry and endo-anal ultrasound were assessed preoperatively and 3 and 12months after implantation. Thirteen patients (2 male, 11 female) underwent implantation during the study period. Anal sphincter defects were present in 13 (76.9%) patients [external anal sphincter (EAS) defect, 2 (15.4%); internal anal sphincter (IAS) defect 4 (30.8%); EAS+IAS defect, 4 (30.8%)]. Median follow-up was 32months (range 18-37months). There were four complications: one intraoperative (rectal perforation) and three postoperative (one implant extrusion, two implants that required removal due to malposition). At 12months, an average of 9/10 implants remained ideally placed in each patient. THD SphinKeeper® insertion was associated with an improvement in coping/behaviour as measured using FIQOL (p=0.047). However, the procedure did not improve FI scores or anorectal manometry parameters. In this study, SphinKeeper® marginally improved symptoms of FI but there was no significant impact on anorectal manometric measurements. Larger-scale studies are needed to determine the patient cohort most likely to benefit from this procedure.

Under-classified obstetric anal sphincter injuries

Obstetric anal sphincter injuries (OASIs) that are missed at delivery can have long-term consequences. OASIs that are under-classified at delivery are likely to be inadequately repaired, resulting in a persistent anal sphincter defect. We aimed to identify women who have persistent defects on endoanal ultrasound, inconsistent with the original diagnosis, and compare the effect on St Mark's incontinence scores (SMIS). We also aimed to look for changes in numbers of under-classification over time. Records of women attending a perineal clinic who had endoanal ultrasound from 2012 to 2020 were reviewed. Women who had a modified Starck score implying a defect greater than the classification [indicated by the depth of external anal sphincter or internal anal sphincter (IAS) defect] at delivery were identified. A total of 1056 women with a diagnosis of 3a or 3b tears were included. Of these, 120 (11.36%) were found to have a defect greater than the original diagnosis and therefore were incorrectly classified at delivery. Women who had a 3b tear diagnosed at delivery, but had an IAS defect, had a significantly higher SMIS (p< 0.01). When comparing two 4-year periods, there was a significant improvement in the diagnosis of IAS tears. Some women with OASIs that have under-classified OASIs are associated with worse anorectal symptoms. This is likely because of an incomplete repair. Some improvement in diagnosis of IAS tears has been noted. We propose improved training in OASIs can help reduce the number of incorrectly classified tears and improve repair.

Pelvic floor architectural defects in female patients with urge fecal incontinence versus passive fecal leakage: a dynamic ultrasound study.

Fecal incontinence (FI) has two primary subtypes: urgency fecal incontinence (UFI) and passive fecal leakage (PFL). The pathophysiology underlying the subtypes is incompletely understood. To compare the bowel habits, physical examinations and pelvic floor anatomical defects in patients with UFI-dominant FI versus patients with PFL-dominant FI. This is a retrospective cross-sectional study of female patients who presented with fecal incontinence symptoms to our tertiary urogynecology center. All subjects underwent a comprehensive history, physical examination, 3D-static pelvic floor ultrasound, and 2D-dynamic ultrasound of the posterior compartment. Patients with UFI-dominant FI were compared to patients with PFL-dominant FI. One hundred forty-five patients were included in the analysis; 57 categorized as UFI-dominant FI, 69 PFL-dominant FI and 19 categorized as having "both" leakage patterns. In comparing bowel habits, patient with UFI-dominant FI had more frequent bowel movements (15.5 ± SD 13.0/week vs. 10.9 ± SD 7.6 /week, p = 0.022) and were more likely to have loose stools (48.2% vs. 26.1%, p = 0.01). No statistically significant differences were observed in the prevalence of external anal sphincter defect (11.3% vs. 17.2%, p = 0.38) or internal anal sphincter defect (11.3% vs. 19%, p = 0.26) between groups. Finally, patients with UFI-dominant FI had a higher incidence of rectal hypermobility (loss of rectal support on Valsalva) (58% vs. 36.9%, p = 0.025). Patients with urge-predominant FI have increased frequency of bowel movements, looser stools, and increased rectal folding diagnosed via dynamic ultrasound as compared to patients with passive-dominant FI.

Early secondary repair of obstetric anal sphincter injuries (OASIs): experience and a review of the literature.

Secondary anal sphincter repair for a dehisced obstetric anal sphincter injury (OASI) is required following 2.6% of primary repairs. There is growing evidence that instead of delaying repair for 3-6months, early secondary repair of the anal sphincter can be completed within 14days. Our aims were to review the literature and to describe experiences in our unit. This is a narrative review of all published cases reporting outcomes of early secondary repair of dehisced OASIs. In addition, we report a series from Croydon University Hospital (CUH) between 2010 and 2019. Ninety patients from five studies were identified on literature search. Six patients from CUH were included in the case series. Overall, the most common complications following secondary repair included skin dehiscence [10.3% (n= 10)], infection [5.2% (n= 5)] and fistula formation [8.2% (n= 8)]. In our case series, following secondary repair, normal manometric incremental squeeze pressure was found in five women (83%). Also, on endoanal ultrasound, internal anal sphincter (IAS) defects were found in 75% with a history of IAS injury (n= 4). There were no full-thickness external anal sphincter defects. Compared to those requiring primary repair alone, residual defects were significantly larger in thosewho also underwent secondary repair (Starck score 2.1 vs. 5.7, p= 0.01). Early secondary repair is a feasible surgical procedure for the reconstruction of dehisced OASIs. This case series and review of the literature can be used to support clinicians in the management of primary OASI repair dehiscence.

Is pelvic floor muscle contractility an important factor in anal incontinence?

Pelvic floor muscle contractility (PFMC) may contribute to anal continence. The aim of this study was to assess the association between clinical and sonographic measures of PFMC and anal incontinence (AI) symptoms, after controlling for anal sphincter and levator ani muscle (LAM) trauma. This was a retrospective study of 1383 women assessed at a tertiary center between 2013 and 2016. All patients underwent an interview, including the StMark's incontinence score (SMIS) in those who reported AI symptoms, a clinical examination, including assessment of PFMC using the modified Oxford scale (MOS), and four-dimensional translabial ultrasound (TLUS). Sonographic measures of PFMC, i.e. cranioventral shift of the bladder neck (BN) and reduction of anteroposterior (AP) diameter of the levator hiatus, were measured offline using ultrasound volumes obtained at rest and on maximum pelvic floor contraction. The reviewer was blinded to all clinical data. Of the 1383 patients assessed during the study period, seven were excluded due to missing imaging data, leaving 1376 for analysis. Mean age of the participating women was 55 years and mean body mass index was 29 kg/m2 . AI was reported by 221 (16.1%) women, with a mean SMIS of 11.8. Mean MOS grade was 2.3. On TLUS, mean BN cranioventral shift was 5.9 mm and mean AP diameter reduction was 8.1 mm. LAM avulsion and significant external anal sphincter (EAS) defect were diagnosed in 24.8% and 8.7% patients, respectively. On univariate analysis, sonographic measures of PFMC were not associated with AI. Lower MOS grade was associated with symptoms of AI; however, statistical significance was lost on multivariate analysis. Clinical and sonographic measures of PFMC were not significantly associated with AI symptoms after controlling for EAS and LAM trauma. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Risk of obstetric anal sphincter injury with fundal pressure in second stage of labor: Transperineal ultrasound study.

Clinical management of the second stage of labor and effectiveness of preventive measures for severe perineal tears are controversial. The aim of this study was to evaluate the effect of using uterine fundal pressure during the second stage of delivery on obstetric anal sphincter injury (OASI), among primiparous women using three-dimensional (3D) transperineal ultrasonography. A total of 73 women who had their first vaginal birth were included in the study, the fundal pressure group included women where the fundal pressure maneuver was applied (n = 37); and the control group included women who delivered spontaneously without fundal pressure (n = 36). Tomographic ultrasound imaging with 3D transperineal assessment was performed within 48 h of delivery, internal anal sphincter (IAS) and external anal sphincter (EAS) defect were determined. Five (13.5%) women in the fundal pressure group, seven (20%) women in the control group had complete EAS defect (p = 0.4). Complete IAS defect was observed in one (2.7%) woman in the fundal pressure group and two (5.7%) women in the control group (p = 0.5).A Half-moon sign was observed in one woman in both groups (p = 0.9). The rate of other signs was similar in both groups. Multivariate regression models revealed that none of age, fetal birth weight, episiotomy, length of the second stage of labor, fundal pressure application status, and number were independent predictors of complete IAS or EAS defect. Fundal pressure with mediolateral episiotomy during the second stage of delivery does not increase the rate of OASI detected with ultrasonography.

Prevalence of anal sphincter defects and association with anal incontinence in women scheduled for pelvic organ prolapse surgery.

Some women with pelvic organ prolapse (POP) have concomitant symptoms of anal incontinence. Our aim was to assess the prevalence of anal sphincter defects and the association with incontinence in women undergoing POP surgery. Cross-sectional study of 200 women scheduled for POP surgery. They answered yes/no and graded any symptoms of fecal and flatal incontinence on a visual analog scale (0-100). 3D/4D transperineal ultrasound was used to assess internal (IAS) and external anal sphincter (EAS) defects. A defect of ≥30° in ≥4 of 6 slices on tomographic imaging was regarded significant. The association between incontinence and sphincter defects was tested with multivariable logistic regression analysis. The prevalence of any sphincter defect was 50/200 (25%). Combined IAS/EAS defect was found in 19/200 (9.5%) women, 8/200 (4.0%) had isolated IAS, and 23/200 (11.5%) had isolated EAS defects. In women with defect and intact IAS, 37% and 11% reported fecal incontinence, respectively, adjusted odds ratio (aOR) 2.3 (95% confidence interval [CI], 0.7-7.0), p = .147 and in women with defect versus intact EAS, 36% and 9% had fecal incontinence, aOR 4.0 (95% CI, 1.5-10.8), p = .005. In women with defect and intact IAS, 85% versus 43% reported flatal incontinence, aOR 5.2 (95% CI, 1.6-17.2), p = .007 and in women with defect versus intact EAS, 71% versus 43% had flatal incontinence, aOR 1.9 (95% CI, 0.8-4.5), p = .131. One of four women scheduled for POP surgery had an anal sphincter defect. EAS defects were associated with fecal incontinence and IAS defects were strongly associated with flatal incontinence.

Management of subsequent pregnancies following fourth-degree obstetric anal sphincter injuries (OASIS)

ObjectivesThe management of subsequent pregnancy in women who sustained OASIS remains an enigma. Nearly all studies include all grades of OASIS including fourth-degree tears. In addition, most protocols require endoanal ultrasound and anal manometric assessment to provide advice regarding mode of delivery. In reality, most women who sustain an OASI do not undergo these investigations. The aims of our study were firstly to evaluate outcomes of fourth-degree OASIS in terms of sphincter defects, anal manometry and anal incontinence symptoms. Secondly, we wished to review recommendations made regarding subsequent mode of delivery after fourth-degree OASIS according to different published protocols. Study designAn observational study of all women who had undergone a primary repair of a fourth-degree tear and seen in the perineal clinic of a tertiary urogynaecology unit between January 2006 and December 2017. Three-dimensional endoanal ultrasound and anal manometry were performed on all women, and symptoms assessed using the validated modified St Mark’s Score for anal incontinence. Diagnostic test accuracy analysis was performed for use of symptoms in predicting abnormal investigations. Results74 fourth-degree tears were identified (mean follow-up 5.9 months; SD 11.5). Endoanal scan showed an internal anal sphincter defect in 77 % and an external anal sphincter defect in 49 %. Only 18 % had no defect. The mean incremental pressure rise was 12.6 mmHg (SD 15.5). 61 % were asymptomatic with a mean St Mark’s Score of 3.8 (SD 5.4). The presence of symptoms alone had poor accuracy in predicting abnormal investigations. Based on Royal College of Obstetricians and Gynaecologists guidance, only 7% would not be offered a caesarean section as they are asymptomatic women with normal scan and manometry findings and would be counselled for a vaginal delivery. ConclusionsGiven that only a few units offer these specialist investigations to their OASI population, it would be reasonable to offer caesarean section to all women who have sustained a fourth-degree tear. However, in centres where endoanal ultrasound and anal manometry are available, individualised counselling can be offered.

What is a significant defect of the anal sphincter on translabial ultrasound?

The anal sphincter is commonly evaluated with endoanal ultrasound. Recently, translabial ultrasound imaging has been proposed for sphincter imaging, with moderate to good correlation between the methods. An endosonographic defect is defined as one with a radial extension of > 30° in at least two-thirds of the length of the anal sphincter. This is equivalent to defining significant anal sphincter trauma on translabial tomographic ultrasound imaging (TUI) as a defect in at least four of six slices, a definition which has been validated. This study was designed to validate a residual defect angle of > 30° for the definition of significant anal sphincter trauma on translabial ultrasound. This was a retrospective study involving 399 women attending a tertiary urogynecology unit in 2014. All underwent a standardized interview, including determination of St Mark's fecal incontinence score (SMIS), clinical examination and 3D/4D translabial ultrasound examination with the woman at rest and on pelvic floor muscle contraction (PFMC). External (EAS) and internal (IAS) anal sphincter defect angles were measured in individual TUI slices and associations with anal incontinence symptoms, bother score and SMIS were analyzed. There were weak but significant correlations of anal incontinence symptoms, bother score and SMIS with EAS and IAS defect angle, measured on images acquired with the woman at rest and on PFMC. The predictive value of single-slice defect angle on TUI was low, and areas under the receiver-operating-characteristics curves were too low to determine a distinct cut-off value for defect angle. Anal sphincter residual defects on single translabial TUI slices are weakly associated with measures of anal incontinence. Single-slice defect angle is too poor a predictor to allow validation of the 30° defect angle cut-off used in endoanal ultrasound. Larger studies in populations with a higher prevalence of anal incontinence are needed before we can disregard anal sphincter defects smaller than 30° on translabial ultrasound. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

480 High Resolution Transrectal Ultrasound Findings Predict Manometric Responders to Biofeedback Therapy for Anal Incontinence

INTRODUCTION: In the United States, over 8% of adults are affected by anal incontinence (AI), and a large percentage of these patients have a history of damage to their pelvic floor. High resolution three-dimensional transrectal ultrasound (TRUS) can be used to assess for microstructural damage to the pelvic floor muscles. Biofeedback (BFB) therapy is a key intervention for AI in addition to anti-diarrheal medications or fiber supplements but it relies on strengthening and improving coordination of existing pelvic floor structures. TRUS is a promising tool to predict meaningful improvement with BFB. METHODS: This is a retrospective analysis of patients enrolled in BFB for AI between 2015 and 2018 at a tertiary referral motility program. Survey and high resolution anorectal manometry (HR-ARM) data were collected at baseline and during each AI BFB visit. Of the 36 patients who met criteria, 9 had TRUS as part of their care. TRUS images were obtained using a high frequency (7-15MHz) ultrasound probe. Fisher's exact test and t-test were used for statistical analysis. Improvement in maximum squeeze pressure on HR-ARM was defined as increase by greater than 30% or ≥29 mmHg from baseline to final session. RESULTS: Patients were on average 62 years old (SD 10 years), one was male, and the mean BMI was 28.0 (SD 6.7). Five of the 8 women had a suspected obstetric etiology to their AI, while two patients attributed symptoms to surgery, one to radiation therapy, and one to neurologic injury. TRUS revealed microstructural defects in the external anal sphincter (66.7%), internal anal sphincter (77.8%), puborectalis muscle (55.6%), and perineal body (66.7%) as shown in Table 1 Three patients had damage to all 4 structures and this was significantly associated with lack of improvement in squeeze on ARM (P = 0.047). Absence of an external anal sphincter defect trended towards correlation with improvement in squeeze (P = 0.07). Baseline levator hiatus abnormalities did not predict lack of improvement in manometric characteristics (P = 0.17). CONCLUSION: TRUS is an emerging tool to identify microdamage to structures of the pelvic floor including internal and external anal sphincter complexes and other key support structures. As BFB for patient with AI aims to retrain muscle coordination, absence of multiple deficits identified on TRUS may predict positive responders to BFB therapy.

Comparing the diagnostic accuracy of 3 ultrasound modalities for diagnosing obstetric anal sphincter injuries

The optimal imaging modality of obstetric anal sphincter injuries needs to take into consideration convenience, availability, and ability to assess the sphincter morphologic condition. Endoanal ultrasound imaging currently is regarded as the reference standard, but it is not widely available in obstetric units. Exoanal alternatives exist, such as 3-dimensional introital or transperineal ultrasound imaging, which are already readily available in most obstetrics and gynecology units. The primary objective was to evaluate the diagnostic accuracy of 3-dimensional introital and 3-dimensional transperineal ultrasound imaging compared with 3-dimensional endoanal ultrasound imaging as the reference standard for the detection of anal sphincter defects in women who sustained obstetric anal sphincter injuries. The secondary objective was to correlate a diagnosis of anal sphincter defect on imaging to symptoms of anal incontinence, and to assess patient discomfort that is experienced for each imaging modality. A cross-sectional study was conducted of 250 women who sustained obstetric anal sphincter injuries, all of whom underwent 3-dimensional introital, transperineal, and endoanal ultrasound imaging. Introital and transperineal ultrasound imaging were assessed with tomographic ultrasound imaging. All of the women completed a validated modified St Mark's Score and Visual Analogue Score for discomfort. Optimal cut-off values for a significant defect on tomographic ultrasound imaging were defined as those with the greatest sensitivity and specificity based on receiver operating characteristic curves with endoanal ultrasound imaging as the reference standard. Diagnostic test characteristics of introital and transperineal ultrasound imaging were calculated with the use of these optimal cut-offs. Optimal cut-off for a significant external anal sphincter defect was ≥3 of 7 slices; sensitivity and specificity were 0.65 and 0.75 on introital imaging and 0.70 and 0.69 on transperineal ultrasound imaging. Optimal cut-off for a significant internal anal sphincter defect was ≥2 of 5 slices; sensitivity and specificity were 0.59 and 0.84 on introital imaging and 0.43 and 0.97 on transperineal ultrasound imaging. The area under the curve for the diagnosis of external and internal anal sphincter defects ranged from 0.70-0.74 (P<.001) for introital and transperineal imaging. Positive predictive value for external and internal sphincter defects ranged from 0.37-0.63, and negative predictive value ranged from 0.85-0.93 for introital and transperineal ultrasound imaging. Endoanal ultrasound imaging was the only modality for a defect to correlate with symptoms; mean modified St. Mark's score for a defect sphincter was 2.4 (standard deviation, 4.1) and for an intact sphincter was 0.9 (standard deviation, 2.7; P<.01). Introital and transperineal ultrasound imaging were associated with less discomfort than endoanal ultrasound imaging. Endoanal ultrasound imaging remains the most accurate diagnostic imaging modality. With low positive predictive values, introital and transperineal ultrasound imaging are not suitable for the identification of sphincter defects; however, high negative predictive values show a good ability to detect an intact sphincter. The optimal cut-off number of slices on tomographic ultrasound imaging for external and internal anal sphincters allows for standardization of a significant defect. In women with a history of obstetric anal sphincter injuries, introital and transperineal ultrasound imagings are suitable to screen for an intact sphincter if endoanal ultrasound imaging is not available. When defects are found, women should then have endoanal ultrasound imaging to verify the diagnosis.