External Anal Sphincter Defects Research Articles

Severity of Fecal Urgency and Incontinence in Inflammatory Bowel Disease

Fecal incontinence (FI) and urgency are prevalent symptoms in patients with inflammatory bowel diseases (IBD). It is unclear which factors determine their severity. We evaluated associations of clinical activity, anorectal motility, and endoanal sonography with FI severity in IBD. Fifty-eight consecutive IBD patients and 14 healthy volunteers participated in a cross-sectional, tertiary-center study. Active disease was defined as Crohn's disease activity index ≥ 150 and as simple clinical colitis index > 2. We assessed anal pressures and fatigue rate index (FRI) of the external anal sphincter (EAS) by manometry, rectal compliance and sensitivity by balloon distension, and sphincter defects by endoanal ultrasound. Significant bivariate associations between these parameters and the fecal incontinence severity scale (FISS) were evaluated in multivariate analysis. Twenty-seven patients (47%) reported urgency, 13 of which (22%) reported FI. Defects of the internal anal sphincter (IAS) and the EAS were diagnosed in 14 (24%) and 13 patients (22%), respectively. Patients had significantly lower rectal compliance and FRI compared with controls. FISS demonstrated significant bivariate associations with clinical disease activity (P = 0.0115), FRI (P = 0.0018), sonographic IAS and EAS defects (P < 0.0001 and 0.0059), rectal compliance (P = 0.0001), and volume at the threshold of a constant urge (Vurge, P = 0.0002). In multivariate analysis, FISS was associated with clinical disease activity (P = 0.0325), FRI (P = 0.0367), Vurge (P = 0.0091), and sonographic IAS defect(s) (P = 0.0008). The derived model explained 62% of the variance in FISS (P < 0.0001). Clinical disease activity and manometric and sonographic anorectal parameters are associated with FI severity in IBD. Prospective studies are warranted to evaluate their predictive value in continence outcomes.

Overlapping Compared With End-to-End Repair of Complete Third-Degree or Fourth-Degree Obstetric Tears

Traditional obstetric practice for repair of third-degree or fourth-degree tears of the external anal sphincter has been using an end-to-end technique. Studies reporting that end-to-end repair was associated with higher rates of external anal sphincter defects and associated anal incontinence symptoms led to increased preference by clinicians for performing overlapping repair of obstetric anal sphincter lacerations. This study reports the results of a 3-year follow-up of a randomized controlled trial conducted in women who underwent primary repair of a complete third-degree or fourth-degree obstetric tear with either the overlapping technique or the end-to-end procedure. Participants were primiparous women enrolled at a single tertiary-care academic center between 2001 and 2007. Eligible women were randomized to receive either end-to-end (n = 86) or overlapping (n = 88) external anal sphincter repair. At a follow-up of 1, 2, and 3 years, questionnaires were mailed to participants to determine rates of flatal and fecal incontinence. At 1 year, rates of flatal and fecal incontinence were lower in women who underwent an end-to-end repair than in those who had an overlapping repair. The flatal incontinence rate was 31% for end-to-end repair and 56% for overlapping repair (difference: 25%, with a 95% confidence interval of 6%–43%; P = 0.012). The fecal incontinence rate for end-to-end repair was 7% and for overlapping repair was 16% (difference: 9%, with a 95% confidence interval of −4% to 21%; P = 0.17). By the end of year 2, the difference between the 2 methods of surgical repair had largely disappeared. These findings indicate that at 1-year follow-up, end-to-end repair of complete third-degree or fourth-degree obstetric anal sphincter tears is less likely than overlapping repair to result in anal incontinence. The lower rate of anal incontinence with end-to-end repair is not sustained at 2 years, suggesting no long-term benefit of either technique over the other.

Detection of Anal Sphincter Defects in Female Patients With Fecal Incontinence

Endoanal ultrasound is widely used for the detection of external and internal anal sphincter defects in patients with fecal incontinence. Recently, 3-dimensional transperineal ultrasound has been introduced as a noninvasive imaging method for the detection of these sphincter defects. This study was designed to assess agreement between 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound regarding the detection of anal sphincter defects in women with fecal incontinence. This study was designed as a prospective observational study. The study took place in a university hospital. Between October 2008 and June 2009, all women with concerns of fecal incontinence underwent 2-dimensional endoanal ultrasound as well as 3-dimensional transperineal ultrasound. The main outcome measures are the presence of external and internal anal sphincter defects. Fifty-five patients were included. External and internal anal sphincter defects were observed with 2-dimensional endoanal ultrasound in 27 (49%) and 15 (27%) patients. Three-dimensional transperineal ultrasound detected an external and internal sphincter defect in 19 (35%) and 16 (29%) patients. The Cohen κ coefficient for the detection of external (κ = 0.63) and internal (κ = 0.78) anal sphincter defects was good. This study's limitations include the absence of a surgical examination as the reference standard in the determination of sphincter defects. This study shows good agreement between 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound regarding the detection of anal sphincter defects. Based on these data, 3-dimensional transperineal ultrasound might be considered as a valuable alternative noninvasive investigation method.

The Effects of Age and Childbirth on Anal Sphincter Function and Morphology in 999 Symptomatic Female Patients With Colorectal Dysfunction

Conflicting data exist on the contributions of advancing age and childbirth on the structure and function of the anal sphincter. This study aimed to examine the relative contributions of age and childbirth in a large cohort of women referred for investigation of symptoms of colorectal dysfunction (fecal incontinence and constipation). This study was conducted at a specialist surgical colorectal investigation unit in a university teaching hospital. Retrospective analysis was performed on prospectively collected demographic, symptom profile, and physiologic data from 3686 female patients. Strict exclusion criteria were applied, leaving 999 patients for univariate, multivariate, and logistic statistical modeling. The effects of independent variables alone and in combination on anal sphincter pressures (resting and squeeze increment) and the presence of sphincter defects (internal and external) were expressed as regression coefficients and odds ratios. Median age was 42 years (range, 16-88), and parity was 2 (range, 0-11); 16% were nulliparous. Three hundred sixty patients had fecal incontinence, 352 had constipation, and 287 had combined symptoms. Anal resting tone decreased with age by 0.66 cm H2O per year, and by 4.3 cm H2O per birth, and was associated with both internal and external anal sphincter defects (p = 0.0001 for both). Squeeze increment pressures decreased by 0.3 cm H2O per year, and by 3.8 cm H2O per birth; decreased pressures were, however, only significantly associated with external anal sphincter defects (p = 0.0001) as a result of childbirth. Cesarean delivery was protective against both reduced anal pressures and sphincter defects. Pudendal nerve terminal motor latencies increased bilaterally with age and with vaginal delivery; the impact of both was greater on the left nerve. Rectal sensation was unaffected by age or parity. Aging predominantly affects anal resting pressures; childbirth, particularly instrumental delivery, is detrimental to the structure and function of the external sphincter.

Internal anal sphincter atrophy in patients with systemic sclerosis

SSc is a connective tissue, multisystem disorder of unknown aetiology. The gastrointestinal tract (GIT) is affected in up to 90% of patients. The exact pathophysiology of GIT involvement is not known, but it is related to both neurogenic and myogenic abnormalities as well as possible vascular and ischaemic changes. Thinning of the internal anal sphincter (IAS) has been demonstrated in SSc with faecal incontinence. We aimed to investigate anal sphincter structure in patients with SSc. Forty-four SSc patients [24 symptomatic (Sx) and 20 asymptomatic (ASx)] and 20 incontinent controls (ICs) were studied. Patients underwent anorectal manometry and endoanal US. In the ICs, external anal sphincter defects were more common, but the IAS was less atrophic, evident by both atrophy scores and IAS thickness. There was no significant difference in atrophy scores [Sx: 2 (1.5-3) vs ASx: 2 (1-2)] or IAS thickness [Sx: 1.85 (1.5-2.3) vs ASx: 1.8 (1.7-2.25)] between the Sx and ASx SSc patients. Patients with SSc (both Sx and ASx) have thin and atrophic IAS, suggesting that IAS atrophy develops even in ASx patients and this may be amenable to treatment with sacral neuromodulation.

Predictive factors for percutaneous tibial nerve stimulation for faecal incontinence

IntroductionThough studies1 2 on percutaneous tibial nerve stimulation (PTNS) show it to be a safe and effective treatment for faecal incontinence (FI), there is little information regarding the predictive factors...

Three‐dimensional endoanal ultrasonography of external anal sphincter defects in patients with faecal incontinence: correlation with symptoms and manometry

Anal sphincter anatomy on two-dimensional endoanal -ultrasonography (EUS) does not always correlate with the clinical data. The purpose of this study was to determine whether three-dimensional (3D) measurements yield a better correlation. The study group included consecutive patients who underwent 3D EUS for faecal incontinence over a 2-year period. The medical charts were reviewed for Cleveland Clinic Foundation Fecal Incontinence (CCF-FI) score and manometric pressures. Endoanal ultrasonographic images were reviewed for the presence of an external anal sphincter (EAS) defect and its extent, as determined by the radial angle, length in the sagittal plane and percentage volume deficit. Correlational analyses were performed between the clinical and imaging data. Sixty-one patients of median age 53 years (range 15-82) were evaluated. Thirty-two patients had either a complete (17) or partial (15) EAS defect, and 29 patients had an intact sphincter. The CCF-FI scores were similar in patients with and without an EAS defect (12.5 ± 5.6 and 11.4 ± 5.5, respectively). The intact-sphincter group had a significantly greater EAS length (3 ± 0.4 vs 2 ± 0.62 cm, P = 0.02) and higher mean maximal squeeze pressure (MMSP; 99.7 ± 52.6 vs 66.9 ± 52.9 mmHg, P = 0.009). There were no statistically significant correlations between MMSP, CCF-FI score and EAS status on 3D EUS. Mean percentage volume of the defect was similar in patients with complete and partial tears (14.5 ± 5.5 and 17.5 ± 7.2%, P = 0.25) and showed no correlation with physiological tests or symptom scores. Improvements in external anal sphincter imaging have not yielded a better association with the clinical findings. The lack of clinical differences between patients with different EAS tears may reflect their similar volumetric defects.

Overlapping Compared With End-to-End Repair of Third- and Fourth-Degree Obstetric Anal Sphincter Tears: A Randomized Controlled Trial

The traditional procedure in obstetric practice used to repair external anal sphincter defects has been an end-to-end technique. Clinicians have been concerned, however, by reports of high rates of external anal sphincter defects and associated symptoms of anal incontinence with this technique. In a small retrospective study, another procedure, overlapping repair, lowered the rate of postoperative defects and improved anal function leading to suggestions that the traditional end-to-end surgical repair technique does not restore normal anatomy or function. As a result, some investigators believe that overlapping repair should replace the end-to-end technique as the standard of care. A Cochrane review of 3 randomized trials comparing the overlapping and end-to-end repair techniques reported no difference in flatal or fecal incontinence rates but a lower rate of fecal urgency and a lower anal incontinence scores in the overlapping group. Although these data suggest some advantage of the overlapping repair technique, the 3 trials were limited by deficiencies in design. Limitations included lack of reporting surgeon experience, inclusion of multiparous women and women with partial tears of the external anal sphincter, and lack of clarity in regard to interpreting outcome measures. This randomized controlled trial compared the use of overlapping repair and end-to-end repair of obstetric tears and investigated which of these procedures is associated with a higher rate of flatal incontinence. The study subjects—149 primiparous women who had sustained a complete third- or a fourth-degree tear of the perineum—were randomly assigned to overlapping (n = 74) or end-to-end (n = 75) external anal sphincter repair. The study was conducted at a tertiary care academic center between 2001 and 2007. All participants and follow-up assessment personnel were blinded as to the surgical procedure performed. At the 6-month follow-up, outcome measures examined included rates of flatal and fecal incontinence, rates of internal and external anal sphincter defects using ultrasonography, anal function using anal manometry, and quality-of-life scores. Compared with end-to-end repair, overlapping repair was associated with higher rates of flatal incontinence (61 % vs. 39%); the odds ratio was 2.44, with a 95% confidence interval of 1.2-5.0 (P = 0.015). The rate of fecal incontinence was also higher with overlapping repair (15% vs. 8%) but not statistically significant (P = 0.243). The difference between groups in rates of internal and external anal sphincter defects was not significant. The presence of a defect in both sphincter muscles was associated with a higher rate of fecal incontinence. There was no significant difference in anal sphincter function between the surgical groups. These findings indicate that overlapping repair of third- or fourth-degree obstetric anal sphincter tears is more likely to result in anal incontinence compared with the traditional end-to-end repair procedure. The investigators recommend use of the traditional end-to-end procedure for repair of these tears.

Overlapping Compared With End-to-End Repair of Third- and Fourth-Degree Obstetric Anal Sphincter Tears: A Randomized Controlled Trial

The traditional procedure in obstetric practice used to repair external anal sphincter defects has been an end-to-end technique. Clinicians have been concerned, however, by reports of high rates of external anal sphincter defects and associated symptoms of anal incontinence with this technique. In a small retrospective study, another procedure, overlapping repair, lowered the rate of postoperative defects and improved anal function leading to suggestions that the traditional end-to-end surgical repair technique does not restore normal anatomy or function. As a result, some investigators believe that overlapping repair should replace the end-to-end technique as the standard of care. A Cochrane review of 3 randomized trials comparing the overlapping and end-to-end repair techniques reported no difference in flatal or fecal incontinence rates but a lower rate of fecal urgency and a lower anal incontinence scores in the overlapping group. Although these data suggest some advantage of the overlapping repair technique, the 3 trials were limited by deficiencies in design. Limitations included lack of reporting surgeon experience, inclusion of multiparous women and women with partial tears of the external anal sphincter, and lack of clarity in regard to interpreting outcome measures. This randomized controlled trial compared the use of overlapping repair and end-to-end repair of obstetric tears and investigated which of these procedures is associated with a higher rate of flatal incontinence. The study subjects—149 primiparous women who had sustained a complete third- or a fourth-degree tear of the perineum—were randomly assigned to overlapping (n = 74) or end-to-end (n = 75) external anal sphincter repair. The study was conducted at a tertiary care academic center between 2001 and 2007. All participants and follow-up assessment personnel were blinded as to the surgical procedure performed. At the 6-month follow-up, outcome measures examined included rates of flatal and fecal incontinence, rates of internal and external anal sphincter defects using ultrasonography, anal function using anal manometry, and quality-of-life scores. Compared with end-to-end repair, overlapping repair was associated with higher rates of flatal incontinence (61% vs. 39%); the odds ratio was 2.44, with a 95% confidence interval of 1.2–5.0 (P = 0.015). The rate of fecal incontinence was also higher with overlapping repair (15% vs. 8%) but not statistically significant (P = 0.243). The difference between groups in rates of internal and external anal sphincter defects was not significant. The presence of a defect in both sphincter muscles was associated with a higher rate of fecal incontinence. There was no significant difference in anal sphincter function between the surgical groups. These findings indicate that overlapping repair of third- or fourth-degree obstetric anal sphincter tears is more likely to result in anal incontinence compared with the traditional end-to-end repair procedure. The investigators recommend use of the traditional end-to-end procedure for repair of these tears.

Outcome of primary repair of obstetric anal sphincter injuries (OASIS): does the grade of tear matter?

To assess risk factors and outcome of different grades of obstetric anal sphincter injuries (OASIS) after primary repair, and to assess the relationship between outcome of anal sphincter defects as diagnosed by endoanal ultrasound. We included 531 consecutive women (of which eight were tertiary referrals) who had sustained OASIS, underwent primary sphincter repair and were followed up between July 2002 and July 2008. At follow-up, defecatory symptoms and bowel-related quality of life (QoL) were evaluated and anal manometry and endoanal ultrasound were performed. The mean time of follow-up was 9 (SD, 5.9) weeks after delivery. Compared with women with a minor (Grade 3a/3b) tear, those with a major (Grade 3c/4) one had a significantly poorer outcome (P < 0.05) with respect to the development of defecatory symptoms and associated QoL as well as anal manometry. Women with major tears were significantly more likely to have an endosonographic isolated internal anal sphincter (IAS) or combined IAS and external anal sphincter (EAS) defect. Combined defects were associated with a higher risk of loose fecal incontinence and lower anal canal pressures. Use of epidural analgesia was the only independent factor predicting a major tear. The greater likelihood of endosonographic anal sphincter defects in women with major tears compared with minor tears is the probable cause of the less favorable outcome of primary repair. Endosonographic combined defects are associated with poorer outcome and it is therefore important to identify the full extent of injury at delivery in women who sustain OASIS, and to pay particular attention to repair of IAS defects.

Overlapping Compared With End-to-End Repair of Third- and Fourth-Degree Obstetric Anal Sphincter Tears

To compare overlapping repair with end-to-end repair of obstetric tears and to investigate which procedure results in a higher rate of flatal incontinence. One-hundred forty-nine primiparous women sustaining a complete third- or a fourth-degree tear of the perineum were assigned randomly to a primary sphincter repair using either an end-to-end (n=75) or an overlapping surgical technique (n=74) using 3-0 polyglyconate. Outcome measures at 6 months included rates of flatal and fecal incontinence, quality-of-life scores, integrity of the internal and external anal sphincters by anal ultrasonography, and anal sphincter function as reflected by anal manometry. Women who underwent overlapping repair compared with end-to-end repair had higher rates of flatal incontinence, 61% compared with 39% (odds ratio [OR] 2.44, confidence interval [CI] 1.2-5.0). The rate of fecal incontinence was also higher, 15% compared with 8% (OR 1.97, CI 0.62-6.3) but did not attain statistical significance. Rates of internal and external anal sphincter defects did not differ significantly between groups and did not correlate with anal incontinence symptoms. Fecal incontinence was higher when there was a defect in both sphincter muscles. Anal sphincter function as assessed by manometry did not differ significantly between groups. End-to-end repair of third- or fourth-degree obstetric anal sphincter tears is associated with lower rates of anal incontinence when compared with overlapping repair. ISRCTN Register, isrctn.org, ISRCTN04149919. I.

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

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

Anterior Sphincteroplasty for Fecal Incontinence: Is the Outcome Compromised in Patients With Associated Pelvic Floor Injury?

It has been shown that vaginal delivery may result not only in sphincter defects, but also in pelvic floor injury. However, the influence of this type of injury on the etiology of fecal incontinence and its treatment is unknown. The present study was aimed to assess the prevalence of pelvic floor injury in patients who underwent anterior sphincteroplasty for the treatment of fecal incontinence and to determine the impact of this type of injury on the outcome of this procedure. Women who underwent anterior sphincteroplasty in the past were invited to participate in the present study. With transperineal ultrasound, which has been developed recently, pelvic floor integrity was examined in 70 of 117 patients (60%). Follow-up was obtained from a standardized questionnaire. The median time period between anterior sphincteroplasty and the current assessment was 106 (range, 15-211) months. Pelvic floor injury was diagnosed in 43 patients (61%). Despite the prior sphincteroplasty, an external anal sphincter defect was found in 20 patients (29%). Outcome did not differ, neither between patients with and those without pelvic floor injury, nor between patients with and those without an adequate repair. However, patients with an adequate repair and an intact pelvic floor did have a better outcome than patients with one or both abnormalities. The majority of female patients with incontinence who were eligible for anterior sphincteroplasty have concomitant pelvic floor injury. Based on the present study, it seems unlikely that this type of injury itself has an impact on the outcome of anterior sphincteroplasty.

Endo-anal ultrasound versus endo-anal magnetic resonance imaging for the depiction of external anal sphincter pathology in patients with faecal incontinence: a systematic review

To evaluate the endo-anal ultrasound (EAUS) versus endo-anal magnetic resonance imaging (EAMRI) in the diagnosis of external anal sphincter defects (EAS) in patients with faecal incontinence (FI). Studies on EAUS and EAMRI were selected and analyzed to generate summative data. Five studies encompassing 347 patients of FI were included in this review. Three studies validated the results of EAUS and EAMRI by surgery (61 patients). In the fixed effect model, EAUS was superior to EAMRI in the depiction of EAS defects. On combined analysis of five studies using fixed effect model, both EAUS and EAMRI were equally effective. However, there was a significant heterogeneity between studies. EAUS and EAMRI are comparable in the diagnosis of EAS defects in patients of FI. Since EAUS is an economical, quicker and easily available imaging modality, it may be used a preferable investigation for the diagnosis of EAS defects in patients of FI.

Factors Associated with Percutaneous Nerve Evaluation and Permanent Sacral Nerve Modulation Outcome in Patients with Fecal Incontinence

Sacral nerve modulation is an established treatment for fecal incontinence. Little is known about predictive factors for successful percutaneous nerve evaluation (or test stimulation) and permanent sacral nerve modulation outcome. The purpose of this retrospective study was to discover predictive factors associated with temporary and permanent stimulation. We analyzed data from test stimulations performed in patients with fecal incontinence from March 2000 until May 2007. Successful outcome was defined as >50% improvement of incontinence episodes in three weeks. Patients with a successful test stimulation were eligible for permanent sacral nerve modulation implantation. All patients who subsequently had permanent sacral nerve modulation were analyzed. Logistic regression was used to determine the predictive power of baseline demographics and diagnostic variables. Test stimulations were performed in 245 patients (226 females; mean age, 56.6 (standard deviation, 12.8) years). Our analysis showed that older age (P = 0.014), external anal sphincter defects (P = 0.005), and repeated procedures after initial failure (P = 0.001) were significantly related to failure. One hundred seventy-three patients (70.6%) were eligible for permanent sacral nerve modulation implantation. The analysis showed no significant predictive factors related to permanent sacral nerve modulation. Three predictive factors were negatively associated with the outcome of test stimulation: older age, repeated procedures, and a defect in the external anal sphincter. These factors may indicate lower chances of success for test stimulation but do not exclude patients from sacral nerve modulation treatment. Although assessed in a selected patient group, no factors were predictive of the outcome of permanent stimulation.

Anterior Sphincteroplasty for Fecal Incontinence: A Single Center Experience in the Era of Sacral Neuromodulation

Anterior sphincteroplasty is the surgical treatment of choice for patients with fecal incontinence associated with an external anal sphincter defect. Recently it has been reported that patients with such a defect may also benefit from sacral neuromodulation. The success of this technique raises the question whether anterior sphincteroplasty still deserves a place in the surgical treatment of fecal incontinence. This study investigated the outcome of anterior sphincteroplasty in a large cohort of patients. A consecutive series of 172 patients underwent anterior overlapping sphincteroplasty. A standardized questionnaire concerning current continence status, overall satisfaction, and quality of life was used to assess the outcome. Follow-up data were obtained from 75% of the 160 patients who were still alive at the time of the survey. After a median follow-up of 111 (range, 12-207) months, the outcome was still good to excellent in 44 patients (37%). In 28 patients (23%), the outcome was classified as moderate because these patients still experienced regular incontinence for stool. However, they were satisfied with their outcome because their incontinence episodes had been reduced by 50% or more. The outcome was poor in 40% of the patients. Predictors of worse outcome were older age (> or =50 years) at surgery, deep wound infection, and isolated external anal sphincter defects. Patients with follow-up of five or more years had the same outcome as patients with follow-up of fewer than five years. Anterior sphincteroplasty results in an acceptable to excellent long-term outcome in 60% of patients, especially in those under the age of 50 years at surgery.

Changes in Anorectal Morphologic and Functional Parameters After Fistula-in-Ano Surgery

This study aimed to analyze changes in anal continence and morphologic and functional anorectal variables after fistula-in-ano surgery in a patient series with a high rate of complex fistulas. One hundred twenty patients with a mean age of 46.9 (standard deviation, 12.8) years were prospectively analyzed by evaluating anal continence, results of endoanal ultrasound examination and anorectal manometry, and pudendal nerve terminal motor latency before and after fistula-in-ano surgery. Forty-three patients (35.8%) were referred for recurrent fistulas; fistulas in and 70 (58.3%) were considered complex. Preoperatively, 17 patients (14.2%) presented with impaired continence. At follow-up, 59 patients (49.2%) had some degree of incontinence (P < 0.001). The techniques that most affected continence were rectal advancement flap and fistulotomy. Endoanal ultrasound examination showed that the number of patients with internal anal sphincter defects increased from 37 (30.8%) to 78 (74.3%) after surgery (P < 0.001); those with external anal sphincter defects increased from 17 (15.9%) to 34 (32.4%) (P < 0.001). Techniques most associated with increases in internal anal sphincter defects were fistulotomy (P < 0.003) and rectal advancement flap (P < 0.004). Anal manometry showed significant decreases in maximal resting pressure and maximum squeeze pressure in patients with previous incontinence (P < 0.001), and in those with internal anal sphincter defects (P < 0.001). Fistulotomy decreased both resting pressure (P < 0.004) and squeeze pressure (P < 0.007), whereas rectal advancement flap significantly reduced only resting pressure. Pudendal nerve latency did not differentiate continent and incontinent patients, and showed no postoperative change. Anal continence is significantly affected after fistula-in-ano surgery, mainly because of sphincteric lesions that affect anal canal pressures and that can be imaged with endoanal ultrasound. It is important to preoperatively recognize sphincter defects to allow adequate surgical treatment.

Perineum compression during EAUS enhances visualization of anterior anal sphincter defects

Endo-anal ultrasound (EAUS) can detect anal sphincter injuries. However, anterior external anal sphincter (EAS) defects can be difficult to define. We assessed different EAUS techniques to determine if any particular method improved defect identification. Ninety females with faecal incontinence were prospectively studied. Wexner faecal incontinence scores were obtained. All patients underwent anorectal manometry and EAUS using three different techniques: standard, digit-assisted (gloved finger pressing on posterior vaginal wall) and balloon-assisted (standard balloon inflated into the vagina). The three techniques were assessed by comparing defect characteristics (detection, angle, edges and scar tissue), and perineal body thickness. All measurements were performed at the mid anal canal level. are expressed as medians (IQR). Results Standard EAUS (S-EAUS) identified a sphincter defect in 54 patients. Digit assisted EAUS (D-EAUS) and balloon-assisted EAUS (B-EAUS) ultrasound revealed a sphincter defect in additional 11 and 9 patients respectively compared to S-EAUS. Correlation of maximum squeeze pressure with EAUS findings improved on D-EAUS and B-EAUS. The defect angle was significantly wider with D-EAUS and B-EAUS [S-EAUS 90 degrees (63-97), D-EAUS 100 degrees (81-101.5), B-EAUS 100 degrees (80-105), P = 0.0005]. The perineal body was significantly thicker when measured with B-EAUS [D-EAUS 9 mm (7-10) vs B-EAUS 10 mm (8-11), P = 0.0005]. Inter-observer agreement was comparable [S-EAUS (K) = 0.677, D-EAUS (K) = 0.658, B-EAUS (K) = 0.601]. EAS anterior defect detection and definition on EAUS may be improved by the demarcation and gentle pressure on the posterior vaginal wall.

Anal sphincter defects and anal incontinence symptoms after repair of obstetric anal sphincter lacerations in primiparous women

A study was carried out to identify (1) incidence of anal incontinence symptoms, (2) incidence and size of both external anal sphincter (EAS) and internal anal sphincter (IAS) defects, and (3) relationship between anal incontinence symptoms and IAS or EAS defect size after repair of an obstetric anal sphincter laceration. Forty-seven vaginally primiparous women underwent obstetric anal sphincter laceration repair. At 8-12 weeks postpartum, anal incontinence symptoms were assessed, and endoanal ultrasound was performed. At 1-2 years postpartum, symptoms were reassesseds. The incidence of anal incontinence symptoms at 8-12 weeks was 43%. The incidence of IAS and EAS defects were 32% and 77%, respectively. IAS defects > or = 45 degrees were predictive of symptoms (p = 0.02). After 18 months mean follow-up, 11% reported chronic symptoms. After anal sphincter laceration repair, anal incontinence symptoms occur in 43% of women and remain chronic in 11%. Anal incontinence symptoms are associated with increasing IAS defect size.

Sacral Nerve Stimulation for Fecal Incontinence: External Anal Sphincter Defect vs . Intact Anal Sphincter

This prospective study was designed to assess the effectiveness of sacral nerve stimulation for fecal incontinence in patients with external anal sphincter defect and to evaluate its efficacy regarding presence and size of sphincter defect. Fifty-three consecutive patients who underwent sacral nerve stimulation for fecal incontinence were divided into two groups: external anal sphincter defect group (n = 21) vs. intact sphincter group (n = 32). Follow-up was performed at 3, 6, and 12 months with anorectal physiology, Wexner's score, bowel diary, and quality of life questionnaires. The external anal sphincter defect group (defect <90 degrees:defect 90 degrees-120 degrees = 11:10) and intact sphincter group were comparable with regard to age (mean, 63 vs. 63.6) and sex. Incidence of internal anal sphincter defect and pudendal neuropathy was similar. All 53 patients benefited from sacral nerve stimulation. Weekly incontinent episodes decreased from 13.8 to 5 (P < 0.0001) for patients with external anal sphincter defects and from 6.7 to 2 (P = 0.001) for patients with intact sphincter at 12-month follow-up. Quality of life scores improved in both groups (P < 0.0125). There was no significant difference in improvement in functional outcomes after sacral nerve stimulation between patients with or without external anal sphincter defects. Clinical benefit of sacral nerve stimulation was similar among patients with external anal sphincter defects, irrespective of its size. Presence of pudendal neuropathy did not affect outcome of neurostimulation. Sacral nerve stimulation for fecal incontinence is as effective in patients with external anal sphincter defects as those with intact sphincter and the result is similar for defect size up to 120 degrees of circumference.