Incontinence In Group Research Articles

Descending Perineum Syndrome: Are Abdominal Hysterectomy and Bowel Habits Linked?

This retrospective study evaluates the effect of abdominal hysterectomy on patients affected by descending perineum syndrome. Eighty-nine female patients affected by descending perineum syndrome and one group of 10 healthy women with normal bowel habits were studied retrospectively. Thirty-two descending perineum syndrome patients (Group 1) had received an abdominal hysterectomy for benign diseases, while 57 descending perineum syndrome patients (Group 2) had not undergone this surgery. All 99 subjects underwent clinical evaluation, computerized anorectal manometry, and defecography. Dyschezia was found predominantly in Group 2 subjects (P < 0.05). Fecal incontinence was significantly higher in Group 1 than in Group 2 (P < 0.05). The worst anal resting pressure was found in the incontinent Group 1 patients (P < 0.01). Rectoanal intussusception was a significant defecographic sign in Group 1 subjects (P < 0.05). Clinical evaluation and instrumental data suggested a possible link between fecal incontinence and abdominal hysterectomy in patients affected by descending perineum syndrome.

Bowel and bladder continence, wound healing, and functional outcomes in patients who underwent sacrectomy

Total or partial sacrectomy is a rare procedure in patients with locally invasive tumors involving the sacrum; it may be associated with functional loss, such as bowel and bladder dysfunction and gait abnormality. In this study the authors examined functional outcome following sacrectomy. The authors reviewed the charts of 50 consecutive patients who had undergone sacrectomy between July 1993 and August 2002. There were 23 male and 27 female patients whose mean age was 46 years (range 13-86 years). Twelve patients with rectal cancer underwent a separate analysis. The patients without rectal cancer were divided into two groups: those who had undergone colostomy for bowel diversion (Group 1, six cases), and those who had not (Group 2, 32 cases). In Group 1 patients the median hospital length of stay (LOS) was 48.5 days (the 25th% and 75th percentiles are 26 and 58, respectively), and in Group 2 patients the median LOS was 18.5 days (the 25th and 75th percentiles are 8 and 41, respectively; p = 0.14). In Group 2 (non-rectal cancer without colostomy), LOS was greater in patients in whom a myocutaneous flap was used compared with those in whom no flap was used (36 days compared with 8.5 days, respectively; p = 0.0012); in patients with bowel incontinence the median LOS was significantly longer than that in patients with bowel continence (39 days compared with 8 days, respectively; p = 0.0026). The incidence of bowel incontinence in Group 2 was closely related to the integrity of the S-3 nerve root (p = 0.05). Awareness of the association between S-3 nerve root resection and bowel and bladder incontinence may help surgeons' decision-making process.

Pelvic Floor Symptoms and Lifestyle Factors in Older Women

To measure the prevalence of pelvic floor symptoms in noncare-seeking older women and the association between symptoms and lifestyle factors. Women enrolled at one site of the Women's Health Initiative Hormone Therapy clinical trial completed a questionnaire, modified from the Pelvic Floor Distress Inventory, on bladder, bowel, and prolapse symptoms. Individual symptoms and symptom groups were examined in a cross-sectional analysis. In the 297 women who participated, mean age was 68.2 years, mean body mass index (BMI) was 30.2 kg/m(2), and median vaginal parity was 3. The median number of symptoms endorsed was 3 (range 0-18). The most prevalent symptoms were stress urinary incontinence (51.2%), urge urinary incontinence (49.2%), urinary frequency (29.0%), straining for bowel movements (25.0%), a sense of incomplete bowel movements (34.8%), and involuntary loss of gas (33.0%). The symptom groups most frequently endorsed were stress urinary incontinence, overactive bladder, obstructive voiding, and obstructive colorectal groups (>/=1 symptom per group in 51.2%, 61.3%, 40.8%, and 48.3%, respectively). In analyses adjusted for age, BMI, caffeine ingesting, smoking, and exercise, older women more frequently reported incomplete bladder emptying (adjusted OR 3.4, 95% CI 1.3, 9.2), weak urinary stream (adjusted OR 6.4, 95% CI 2.0, 20.0), intermittent urinary stream (adjusted OR 4.0, 95% CI 1.6, 10.4), and a feeling of incomplete bowel movements (adjusted OR 2.7, 95% CI 1.2, 5.9). Women who exercised weekly had less fecal urgency (adjusted OR 0.3, 95% CI 0.2, 0.8). Coffee drinking was associated with difficulty emptying the bladder (adjusted OR 8.6, 95% CI 1.4, 55.0) and weak stream (adjusted OR 5.3, 95% CI 1.5, 19.0). Pelvic floor symptoms, especially urinary incontinence and irritative and obstructive urinary and bowel symptoms, are common in older women. Some symptoms are associated with potentially modifiable lifestyle factors.

Investigation of the Pathophysiology of Fecal Seepage

Unintentional seepage of stool without awareness is common but its pathophysiology is poorly understood. Our aim was to examine the underlying mechanism(s) for fecal seepage. We evaluated prospectively 25 patients with fecal seepage, by performing anorectal manometry, balloon expulsion, saline infusion, pudendal nerve latency tests, and symptom assessments and compared their data with 26 fecal incontinence patients and 43 healthy controls. Predisposing factors for fecal seepage were back injury (7), obstetric injury (6), hemorrhoidectomy (3), pelvic radiotherapy (1), and unknown (8). In the seepage group, the resting and squeeze sphincter pressures were lower (p < 0.02) than healthy controls, but higher (p < 0.002) than incontinent group. During straining, the intrarectal pressure and defecation index were lower (p < 0.05) in the seepage group compared to controls; 72% showed dyssynergia and balloon expulsion time was prolonged (p < 0.01). Threshold for first rectal sensation was impaired (p < 0.002) in the seepage group compared to controls and incontinent group. The seepage group retained more (p < 0.001) saline than the incontinent group but pudendal nerve latency time was impaired (p < 0.05) in both patient groups compared to controls. Anal sphincter function and rectal reservoir capacity were relatively well preserved but most patients with seepage demonstrated dyssynergia with impaired rectal sensation and impaired balloon expulsion. Thus, incomplete evacuation of stool may play a significant role in the pathogenesis of seepage.

Three-dimensional transrectal ultrasound of the male urethral rhabdosphincter.

The rhabdosphincter of the male urethra is an omega-shaped loop of striated muscle fibers that surrounds the membranous urethra at its lateral and anterior aspects. We investigated whether this muscle can be visualized by means of three-dimensional ultrasound to define morphological and dynamic ultrasound criteria. We examined the rhabdosphincter of the male urethra in 77 patients by means of this new imaging technique; 37 patients presented with urinary stress incontinence after transurethral resection of the prostate or radical prostatectomy while 40 were fully continent after radical prostatectomy and served as a control group. Contractility of the muscle was quantified by a specially defined parameter (rhabdosphincter-urethra distance). The anatomical arrangement and the contractions of the rhabdosphincter-loop could be clearly visualized in three-dimensional transrectal and transurethral ultrasound; during contraction the rhabdosphincter retracts the urethra, pulling it towards the rectum. We detected defects and postoperative scarrings in the majority of the patients with postoperative urinary stress incontinence. Furthermore, the patients presented with thinnings in parts of the muscle and atrophies of the rhabdosphincter. The rhabdosphincter-urethra distance was significantly lower in the incontinent group than in the continent group (59 vs. 1.42 mm). Our study shows that the rhabdosphincter of the male urethra can be visualized by means of three-dimensional transrectal ultrasound. The sonographic pathomorphological findings of postoperative urinary stress incontinence are well correlated well with the clinical symptoms.

Changes in urinary incontinence and quality of life after four yearsA population-based study of women aged 22–50 years

Objectives – To investigate (a) the incidence and remission rates of female urinary incontinence (UI), (b) changes in type of UI and quality of life (QoL), and (c) whether professional help had been consulted regarding UI.Design – A 4-year follow-up population-based cohort study.Setting – Surahammar, Sweden, a community of 10,500 inhabitants.Subjects – All 118 incontinent and 130 continent women aged between 22 and 50 years.Main outcome measures – Changes in type of UI were measured using the Detrusor Instability Score (DIS), which was used to distinguish between the stress incontinent and the urge incontinent women. Changes in QoL were measured using the SF-36 Health Survey.Results – The mean annual incidence and remission rates of UI were the same (4%). The majority of women (83%) reported unchanged UI after 4 years and 77% of these women had stress incontinence. At follow-up, the changes in QoL scores were significantly greater in five out of eight dimensions in the persistently incontinent group compared with the persistently continent group. QoL scores did not change significantly from baseline to the 4-year follow-up within the incidence and remission groups. Three of four women with UI had not sought professional help.Conclusions – At 4-year follow-up the type of UI is fairly stable in women below 50 years of age. The QoL decreases in five dimensions, but the clinical relevance of this might be questioned. Most women with UI had not sought professional help.

Predictive Value of Maximum Urethral Closure Pressure, Urethral Hypermobility and Urethral Incompetence in the Diagnosis of Clinically Significant Female Genuine Stress Incontinence

We determined the value of urethral hypermobility, maximum urethral closure pressure (MUCP) and urethral incompetence in the diagnosis of stress urinary incontinence (SUI). In this study 369 women with clinical symptoms suggestive of SUI without symptoms of bladder overactivity were evaluated in regard to urethral incompetence, urethral hypermobility and mean MUCP. The cohort was divided into 2 groups according to continence/incontinence status. ROC curves were used to test the performance of the various predicting factors. These factors were combined in forward stepwise logistic regression to find the cutoff point that simultaneously optimized sensitivity and specificity. Continent and incontinent patients differed with regards to urethral incompetence and hypermobility (each p <0.0001). Incontinent patients had a greater probability of a higher grade of each factor. Even after adjusting for the older age of incontinent patients by ANCOVA. MUCP was significantly lower in the incontinent group (p <0.001). The best univariate optimized cutoff point for discriminating continence from incontinence was obtained with urethral incompetence greater than grade I. The best single predictor of clinically significant SUI is urethral incompetence, followed by urethral hypermobility and MUCP. When combining several factors, namely grade II urethral incompetence with grade III hypermobility, grade III urethral incompetence with grades I to III hypermobility and grade IV urethral incompetence with or without urethral hypermobility, all indicated more than a 90% probability of clinically significant SUI.

Fatigability of the external anal sphincter in anal incontinence.

Anal incontinence commonly results from external anal sphincter dysfunction. The muscle is routinely assessed by anorectal physiology studies. Fatigability is not routinely measured but should be an important factor in the maintenance of continence. The fatigue rate index has been developed to address this. The purpose of this study was to investigate the fatigability of the external anal sphincter in incontinent patients compared with that in controls and to determine its correlation with symptom severity and pudendal nerve terminal motor latency measurement. Forty-two patients with anal incontinence (33 female, 9 male) and 20 control patients (17 female, 3 male) were studied. As part of anorectal physiology studies, manometry was measured by a station pull-through technique with a closed-system microballoon. After a rest period of one minute, fatigue was measured over a 20-second squeeze at 1.5 cm in the anal canal with two consecutive readings separated by a further one-minute rest period. The fatigue rate index was calculated from the maximum squeeze pressure and fatigue rate. A validated symptom severity scoring system was used to assess symptomatology in patients with anal incontinence. No difference was detected in demographic factors between the two groups. The fatigue rate index was significantly different between the control and incontinent groups (1.85 vs. 0.67 minutes, P = 0.001). No other factors were significantly different between the two groups (maximum squeeze pressure, 89.1 vs. 79 cm H(2)O, P = 0.42; fatigue rate, -85.8 vs. -101.2 cm H(2)O/min, P = 0.62). The fatigue rate index demonstrated a significant correlation with symptom score ( r = -0.44, P = 0.005). The fatigue rate index did not correlate with latency measurement. A significant difference was detected in the fatigue rate index between incontinent and control patients. The Fatigue Rate Index demonstrated a significant correlation with symptom severity score and it may be a useful discriminating measure of external anal sphincter function.

Are fatigue and disturbances in pre-programmed activity of pelvic floor muscles associated with female stress urinary incontinence?

To investigate whether there is a difference between a continent versus a stress urinary incontinent group of women regarding: (i) fatigue in pelvic floor muscles, and (ii) pre-activation times between pelvic floor and abdominal muscles during coughing. Twenty-six continent and 20 stress urinary incontinent parous women were examined. Fatigue was measured with an intravaginal device. Time to 10% decline of the initial reference force (RF) was defined as time-to-fatigue. Simultaneous recordings of force developed in levator ani muscle and electromyographic activity in the external oblique abdominal muscle were performed to determine whether contraction of pelvic floor muscles precedes activity in abdominal muscles during coughing. Time-to-fatigue was identical in the two groups (10.5 sec in the continent and 11.5 sec in the incontinent group, median values). Normalized force was significantly reduced in the incontinent group. The pelvic floor muscles contracted 160 msec before the abdominal muscles in both groups. In 24% of the continent and in 30% of the incontinent women, however, abdominal muscle activity preceded activity of pelvic floor muscles. Muscular fatigue, defined as rate of force loss, does not seem to be associated with urinary stress incontinence. Moreover, muscular activity recruitment patterns were equal in both groups suggesting that other factors than disturbances of ordered muscle recruitment, that is, pelvic floor followed by abdominal muscles, may be responsible for stress urinary incontinence. It is likely that reduced normalized force, as found in the incontinent group, is an important contributing factor.

Clinical evaluation of pelvic floor muscle function in continent and incontinent women

The aim of the study was to investigate the reliability of a scoring system for the investigation of voluntary and reflex co-contractions of abdominal and pelvic floor muscles in lying, sitting, and standing positions in continent and incontinent women. A visual inspection and digital (strength, tone, speed, and endurance) palpation scale was developed to measure the coordination of the lower abdominal and pelvic floor muscles. Inter-observer reliability of the scales was investigated in 40 continent and 40 incontinent women. Differences between the continent and incontinent group were analysed. Inter-observer reliability for the visual inspection scale showed kappa values between 0.91 and 1.00, for tone percentage of agreement ranged from 95 to 100% (superficial) and 95 to 98% (deep muscle). Weighted Kappa (K(w)) varied from 0.77 to 0.95 for strength and 0.75 to 0.98 for the inward movement of superficial and deep pelvic floor muscles. K(w) for coordination between the superficial and deep part of the pelvic floor muscles groups was from 0.87 to 0.88 and 0.97 to 1.00 for endurance and global speed of the pelvic floor contraction. The continent women exhibited significantly better coordination between the pelvic floor and lower abdominal muscles during coughing in all three positions. Also the superficial part of the inward movement, the feeling and the coordination of the pelvic floor muscles were significantly better in the continent group. Visual inspection and digital tests are easy and reliable methods by which insight can be gained into the multi-muscular activity and coordination of the pelvic floor and lower abdominal muscles in continent and incontinent women.

Urethral pressure changes in response to squeeze: a population-based study in healthy and incontinent 53- to 63-year-old women

Objective The purpose of this study was to investigate the urethral pressure pattern during short squeezes in incontinent and healthy women before and after pelvic floor exercise and to correlate the findings with vaginal measurements. Study design Sixty women with urinary incontinence and 28 healthy control subjects all aged 53 to 63 years were subject to urethral pressure measurements and vaginal palpation, pressure and surface electromyography measurements. Measurements were repeated after 4 months of pelvic floor exercise in the incontinent group. Results The appearance of the urethral pressure curve during a squeeze on a semiquantitative scale from 0 to 4, in the healthy group, was 2.2±0.3 and, in the incontinent group, was 1.5±0.2 ( P<.0 5), rising to 2.2±0.2 after pelvic floor exercise ( P<.01). The semiquantitative grading correlated with vaginal measurements. Conclusion The increase of the urethral pressure in response to short squeeze is reduced significantly in incontinent women compared with healthy women of the same age and parity. A normalization was seen after pelvic floor exercise in the incontinent group.

Pain during the TVT procedure performed under local anesthesia.

The aim of this study was to identify patients' reactions to pain during the TVT procedure performed under local anesthesia and to consider whether this is acceptable;to see how many patients under 70 years of age could be discharged from hospital on the day of operation; and to estimate the rate of complications. This was a prospective descriptive study of 110 unselected women operated upon with TVT plasty for urinary stress incontinence under local anesthesia. The patients all received the same oral and written information, care and advice for the perioperative period. A 100 mm non-hatched VAS scale was used, 0 mm equivalent to no pain and 100 mm indicating unbearable pain. New dose analgesia is normally given postoperatively after other surgical procedures in scores over 30 mm on the VAS scale. Eighty-eight percent of patients scored their pain reaction between 0 and 10 mm, 5% at 11-20 mm, 4% between 21 and 30 mm, 2% at 31-40 mm and 1% (1 patient) at 94 mm. Mean value was 5 mm. Seventy-one percent of the total and 85% of those over 70 years old in the stress and mixed incontinent group without prolapse went home on the day of the operation. There were 2% of bladder perforations and 4% postoperative hematomas; 94% of all patients had a residual urine volume <100 ml within 24 hours. During the procedure most patients felt no pain at all and in all cases but one local anesthesia was well tolerated and accepted. The majority of the patients without prolapse could be discharged on the day of the operation. The complication rate was low and did not affect the hospital stay.

Double incontinence in urogynecologic practice: A new insight

OBJECTIVES: This study was undertaken to evaluate the prevalence of anal incontinence in an urogynecologic setting and to investigate the relationship between lower urinary tract dysfunction and anal incontinence. STUDY DESIGN: The study included 504 women referred to our urogynecologic outpatient clinic who were prospectively investigated and asked specific questions on anal incontinence. Clinical and instrumental data were compared between women with urinary incontinence and with double incontinence, with further analysis for subgroups in the anal incontinent group of women (passive/urge). For continuous variables, the Wilcoxon rank sum test was used, and the Fisher exact test was applied to dicotomic variables. Logistic regression was used for categorical data. A level of P<.005 was considered significant. RESULTS: Of the investigated women, 20.2% were also anally incontinent. Women with double incontinence showed higher scores for urinary urgency ( P = .010), which reached the established level of significance only in the subgroup with urge anal incontinence ( P = .003). In this group, a higher prevalence of detrusor overactivity was observed. CONCLUSION: Anal incontinence is highly prevalent among women with lower urinary tract disorders. The existence of subgroups of patients having different kinds of anal and urinary disorders should be taken into consideration both for research purposes and for new treatment perspectives.

Role of fecal incontinence in contamination of the environment with vancomycin-resistant enterococci

Background: We tested the hypothesis that patients with vancomycin-resistant Enterococcus (VRE) stool colonization who are continent of feces contaminate the environment less frequently than patients who are colonized and incontinent. Methods: We prospectively examined the frequency of environmental VRE contamination in the rooms of 15 patients who were continent and 15 who were incontinent and VRE-colonized. Broth-enrichment cultures of bed rails, bedside table, and call buttons were performed at baseline, and 2 and 5 days after environmental disinfection. The numbers of VRE colonies isolated after directly plating environmental swabs onto agar were compared for the continent and incontinent groups. Results: The percentages of patients with 1 or more positive environmental cultures for VRE were not significantly different for the groups of patients who were continent and incontinent at baseline (60% vs 73%, P =.45) or 2 days after disinfection (60% vs 80%, P =.24). The numbers of VRE colonies isolated by direct plating were not significantly different for the continent and incontinent groups (P =.42). Conclusions: Environmental contamination occurs frequently in the rooms of patients who are continent, and those who are incontinent and VRE-colonized. Our findings suggest that similar infection control measures should be implemented for patients who are continent and incontinent. (Am J Infect Control 2003;31:221-5.)

Differences in the quantity of elastic fibres and collagen type I and type III in endopelvic fascia between women with stress urinary incontinence and controls.

The aim of this study was to evaluate whether differences in the quantity of elastic fibres, collagen type I and collagen type III in the endopelvic fascia occur with female stress urinary incontinence (SUI). A total of 54 patients participated in the study. They were divided into two groups (continent and incontinent) that were comparable with respect to age and parity. All patients underwent gynaecologic surgical procedures and biopsies from the endopelvic fascia were obtained. Histological slides were stained with haematoxylin and eosin and Masson trichrome or Weigert's techniques and immunohistochemistry for either collagen type I or type III were performed. The elastic fibres constituted 3.81+/-0.6% and 5.93+/-0.92% of the cross-sectional area of the endopelvic fascia in incontinent and control groups of patients, respectively. Collagen type I and type III were not significantly reduced in patients with SUI. Our results suggest that the quantity of elastic and collagen fibres in the endopelvic fascia does not play a significant role in continence.

The urethra and its supporting structures in women with stress urinary incontinence: MR imaging using an endovaginal coil.

The objective of this study was to evaluate the urethra and its supporting structures in patients with stress urinary incontinence using MR imaging with an endovaginal coil. We reviewed MR images obtained using an endovaginal coil in 63 patients with stress urinary incontinence and in 16 continent women. We compared the two groups for the thickness of the striated muscle, smooth muscle, and mucosa-submucosa of the urethra; degree of asymmetry of the puborectalis muscle; frequency of distortion in the periurethral, paraurethral, and pubourethral ligaments; degree of the vesicourethral angle; and dimension of the retropubic space. Using the status of the urethra and its supporting structures as our basis, we scored the risk of stress urinary incontinence for each woman on a scale of 0-5. The striated muscle layer of the urethra was thinner in the group with stress urinary incontinence (mean +/- SD, 1.9 +/- 0.5 mm) than that in the continent group (2.6 +/- 0.4 mm) (p < 0.001). A high degree of asymmetry of puborectalis muscle (>1.5) was more frequent in the group with stress urinary incontinence (29%) than in the continent group (0%) (p = 0.015). Supporting ligaments were more frequently distorted in the incontinent group than in the continent group. Distorted periurethral ligaments were found in 56% of the patients with stress urinary incontinence versus 13% of the women who were continent; distorted paraurethral ligaments were found in 83% of the patients with stress urinary incontinence versus 19% of the women who were continent; and distorted pubourethral ligaments were found in 54% of the patients with stress urinary incontinence versus 19% of the women who were continent (p < 0.05). The group with stress urinary incontinence had a greater vesicourethral angle (148 degrees vs 125 degrees ) and larger retropubic space (7.5 vs 5.1 mm) than did the women who were continent (p < 0.05). The score for the risk of stress urinary incontinence was higher in the group with stress urinary incontinence (3.3 +/- 1.4) than in the women who were continent (1.0 +/- 1.2) (p < 0.001). MR imaging with an endovaginal coil revealed significant morphologic alterations of the urethra and supporting structures in patients with stress urinary incontinence.

Combining the strength-duration curve of the external anal sphincter with manometry for the assessment of faecal incontinence.

The strength-duration curve of a muscle is thought to be a measure of its innervation. This study was designed to evaluate the ability of the strength-duration curve of the external anal sphincter to discriminate between controls and patients with faecal incontinence. Forty-three women with faecal incontinence due to sphincter weakness were studied together with 45 age-matched women with no disorders of defaecation. Strength-duration curves of the external anal sphincter and anorectal manometry were recorded for all subjects with the additional measurement of pudendal nerve terminal motor latency in the incontinent group. Logistic regression was performed using resting and voluntary squeeze pressures and current strengths at 28 different pulse durations to develop a predictive equation for incontinence. Only currents at 1 and 6 ms were significant predictors. When anorectal manometry data were included, only the current required to elicit contraction at 1 ms was necessary. The following regression equation can be applied to predict continence in this population with a sensitivity of 95 per cent and a specificity of 100 per cent: logit(P)=4.1605-(0.0559 x squeeze pressure)-(0.1755 x resting pressure)+0.8622I(1 ms). A negative value indicates continence. The strength-duration curve, when used in conjunction with anorectal manometry, may have a role in the investigation of faecal incontinence.

The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery

Objective To describe the appearance and occurrence of abnormalities in the levator ani muscle seen on magnetic resonance imaging (MRI) in nulliparous women and in women after their first vaginal birth. Methods Multiplanar proton density magnetic resonance images were obtained at 0.5-cm intervals from 80 nulliparous and 160 vaginally primiparous women. These had been previously obtained in a study of stress incontinence, and half the primiparas had stress incontinence. All scans were reviewed independently by at least two examiners blinded to parity and continence status. Results No levator ani defects were identified in nulliparous women. Thirty-two primiparous women (20%) had a visible defect in the levator ani muscle. Defects were identified in the pubovisceral portion of the levator ani in 29 women and in the iliococcygeal portion in three women. Within the pubovisceral muscle, both unilateral and bilateral defects were found. The extent of abnormality varied from one individual to the next. Of the 32 women with defects, 23 (71%) were in the stress incontinent group. Conclusion Abnormalities in the levator ani muscle are present on MRI after a vaginal delivery but are not found in nulliparas.

Investigations for incontinence and constipation after surgery for Hirschsprung's disease in children.

Surgery for Hirschsprung's disease is associated with high rate of morbidity, in the form of either constipation or incontinence or a combination of the two. This study investigates the mechanisms responsible for incontinence and/or constipation following the pull-through operation for Hirschsprung's disease. There were 19 children (15 boys and 4 girls), who at the time of study; 16 had undergone Duhamel, 1 Rehbein, and 2 Soave operation. We classified patients according to their symptoms into 3 groups: Group A was incontinent of faeces; Group B was constipated and incontinent of faeces, and Group C was constipated only. The median age at referral was 6 years, and the median period after operation was 5 years. All patients were investigated by intestinal transit study, endoanal sonography and anorectal manometry. Group A had normal or rapid transit study, as opposed to Groups B and C, who had delayed-transit study. On endoanal sonography, all children had an intact internal and an external anal sphincter, below the level of pull-through operation. The anorectal manometry showed a significantly lower resting anal pressure in the incontinent Group A as compared to the constipated children with or without incontinence in Group B or C (38 mmHg versus 57 or 66 mmHg respectively). The rectal pressure was also significantly higher in children in Group A as compared to those in Group B or C (71 mmHg versus 42 or 36 mmHg). The ratio of rectal/anal pressure was higher in incontinent children in Group A, as compared to constipated children in Group B or C. Therefore, constipation can be caused by high anal resting pressure and a weak rectal peristalsis, while faecal incontinence can be secondary to poor compliance and elevated rectal pressure in the presence of normal or low anal sphincter resting pressure. Aperients are the mainstay of treatment of constipation, however, children with incontinence are more difficult to treat. We did not attempt to define the pattern of nerve plexus because of poor results of revision operation for residual hypoganglionic segment and intestinal neuronal dysplasia. Treatment of these children can become more rational, if furnished with detailed functional studies. We advocate investigation of the anorectal function at an early stage in symptomatic children after surgery for Hirschsprung's disease, and less invasive treatment should be considered before embarking on major surgery.

Urodynamic Characterisation of Women with Naive Urinary Incontinence: A Population-Based Study in Subjectively Incontinent and Healthy 53–63 Years Old Women

To compare the urodynamic characteristics in a group of middle-aged women with untreated urinary incontinence with the findings in a control group of healthy women. Sixty women with mild-to-moderate urinary incontinence and 28 symptom-free women, 53-63 years old, were randomly chosen out of a large health questionnaire study. All were investigated with a detailed history, gynaecological examination, urinalysis, frequency-volume chart, and urodynamics including cystometry and pressure-flow analysis. The maximum urinary flow was significantly higher in the incontinent group of women, 22+/-1ml/s, than in the healthy controls, 16+/-2ml/s (p<0.01). The acceleration of flow, with a theoretical maximum of 0 degrees, was also significantly faster in the incontinent, 20 degrees, than in the healthy women, 32 degrees (p=0.01). In the five women with urge incontinence only, maximum urinary flow was 26+/-2.4ml/s and the flow acceleration 7 degrees. In incontinent women, both a lower opening pressure and detrusor pressure at maximum flow were seen compared with the healthy women, though the difference did not reach statistical significance. The incontinent and the healthy women did not differ regarding bladder volumes or pressures during filling. The findings of this study indicate the presence of an increased efficiency of the urethral opening mechanism in incontinent women compared to normal, irrespective of the type(s) of symptoms present.