Intact Anal Sphincter Research Articles

Is posterior compartment prolapse associated with anal incontinence?

It has been claimed that manifestations of posterior compartment prolapse, such as rectocele, enterocele and intussusception, are associated with anal incontinence (AI), but this has not been studied while controlling for anal sphincter trauma. We aimed to investigate this association in women with intact anal sphincter presenting with pelvic floor dysfunction. This retrospective study analyzed 1133 women with intact anal sphincter presenting to a tertiary urogynecological center for pelvic floor dysfunction between 2014 and 2016. All women underwent a standardized interview, including assessment of symptoms of AI, clinical examination and three-/four-dimensional transperineal ultrasound. Descent of the rectal ampulla, true rectocele, enterocele, intussusception and anal sphincter trauma were diagnosed offline. Mean age was 54.1 (range, 17.6-89.7)years and mean body mass index was 29.4 (range, 14.7-67.8) kg/m2 . AI was reported by 149 (13%) patients, with a median St Mark's anal incontinence score of 12 (interquartile range, 1-23). Significant posterior compartment prolapse was seen in 693 (61%) women on clinical examination. Overall, 638 (56%) women had posterior compartment prolapse on imaging: 527 (47%) had a true rectocele, 89 (7.9%) had an enterocele and 26 (2.3%) had an intussusception. Women with ultrasound-diagnosed enterocele had a significantly higher rate of AI (23.6% vs 12.3%; odds ratio (OR), 2.21 (95% CI, 1.31-3.72); P = 0.002), but when adjusted for potential confounders, this association was no longer significant (OR, 1.56 (95% CI, 0.82-2.77); P = 0.134). In women without anal sphincter trauma, posterior compartment prolapse, whether diagnosed clinically or by imaging, was not shown to be associated with AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Analysis of the efficacy of biofeedback for faecal incontinence after surgery for anorectal malformation

Objective To explore the therapeutic effects of biofeedback in the treatment of faecal incontinence (FI) after surgery for anorectal malformation (ARM). Methods Clinical data were collected from paediatric patients for postoperative biofeedback due to FI caused by ARM between May 2017 and November 2021. The data included the duration of symptoms, the integrity of the anal sphincter, anorectal manometry parameters, and FI scores. These patients were divided into the low ARM group (group A) and the high ARM group (group B). Results A total of 45 paediatric patients were enrolled in the study. There were 28 cases in group A and 17 cases in group B. The differences in age, gender, and body weight were not statistically significant between the two groups (p > 0.05). The differences in the clinical indicators were also not statistically significant between the two groups at the time of the initial evaluation. The duration of symptoms was 2.21 ± 0.71 years and 4.14 ± 1.89 years in groups A and B. There were 16 cases with an intact anal sphincter in group A and only two cases with an intact anal sphincter in group B. This difference was statistically significant between the two groups (p < .05). The anal resting pressure, initial sensitivity threshold, defaecation sensitivity threshold, defaecation urge threshold, and FI scores were significantly improved in both groups post-treatment compared to pre-treatment (p < .001). Strong impulses improved significantly in group A, while strong impulses did not improve significantly in group B. The multivariate logistic regression analysis with these variables further showed that symptom duration and anal sphincter integrity were the main factors influencing the therapeutic effects of biofeedback. Conclusion Biofeedback plays a positive role in the treatment of FI in paediatric patients following surgery for ARM. Symptom duration and anal sphincter integrity were found to be the main factors influencing the therapeutic effect of biofeedback.

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.

Patient's characteristics and incidence of fecal incontinence after primary repair of Obstetric Anal Sphincter Injuries (OASIS) at three Indonesian tertiary hospitals in 2014-2016.

IntroductionObstetric Anal Sphincter Injuries (OASIS) is a common complication of vaginal delivery. The incidence was 4.53 % of total vaginal deliveries. OASIS is associated with an increased risk of fecal incontinence (FI), which affects one’s quality of life. The incidence of OASIS and FI varied from study to study. In this study, we described the characteristics of patients with OASIS at three Indonesian tertiary hospitals in 2014−2016 and FI outcome among those patients.MethodologyThis is a descriptive study on the characteristics of OASIS patients after primary repair in three tertiary hospitals: dr. Cipto Mangunkusumo National General Hospital, Persahabatan General Hospital and Fatmawati General Hospital from 2014 to 2016. From a total of 234 patients, only 58 patients could be contacted and interviewed using Revised Fecal Incontinence Score (RFIS) questionnaires. Out of the 58 patients, only 16 patients came for transperineal ultrasound. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 20.ResultsFrom a total of 234 patients, the mean age was 26.6 years old with a mean Body Mass Index (BMI) of 24.8 kg/m2. Most of the patients were nulliparous (67.5 %) and the median duration of second stage of labor was 45 min. Episiotomy was not performed on most patients (59.4 %) and most of them underwent spontaneous vaginal delivery (65.4 %) with mean baby’s birthweight of 3217 g. From 58 interviewed patients, three patients complained of FI (5.2 %). Sixteen patients came for transperineal ultrasound examination, and only one of them had FI. Anal sphincter defects were identified in five patients, comprising three external anal sphincter (EAS) and two internal anal sphincter (IAS) defects. All five patients did not experience FI. One patient who had FI had no anal sphincter defect.DiscussionThis is a pilot study for the incidence of FI among the OASIS population in Jakarta, Indonesia. The incidence of FI observed in this study was relatively low (3 out of 58 patients) compared to other studies. This could be due to differences in study population. The fact that the patient with FI had intact anal sphincter suggests that other factors may contribute to the development of FI in addition to the integrity of the anal sphincter. These factors may include pelvic floor muscle and innervation of the surrounding tissues.ConclusionThe outcomes of primary repair of OASIS varied between studies. Patients’ characteristics might play an important role in the development of OASIS as well as the outcome after repair. Further studies with larger sample size are needed.

Overdiagnosis and rising rate of obstetric anal sphincter injuries (OASIS): time for reappraisal.

To determine the accuracy of clinical diagnosis of obstetric anal sphincter injuries (OASIS) using three-dimensional (3D) endoanal ultrasound (EA-US) and to compare symptoms and anal manometry measurements between women with anal sphincters adequately repaired and those with persistent anal sphincter defects. The EA-US images of women with clinically diagnosed and repaired OASIS, defined as third- or fourth-degree perineal tear, who attended the perineal clinic at Croydon University Hospital over a 10-year period (2003-2013) were reanalyzed by a single expert blind to symptoms and the results of clinical examination. St Mark's Incontinence Scores (SMIS) and anal manometry measurements were obtained and compared between women with an intact anal sphincter and those with an anal sphincter scar and between those with an intact anal sphincter and those with a defect. Anal manometry measurements were compared between women with an external anal sphincter (EAS) defect and those with an internal anal sphincter (IAS) defect. The images of 908 women were reanalyzed. No evidence of OASIS was found in 64 (7.0%) women, an EAS scar alone was detected in 520 (57.3%) and an anal sphincter defect in 324 (35.7%). Of the 324 women with a defect, 112 had an EAS defect, 90 had an IAS defect and 122 had a combined IAS and EAS defect. SMIS results were significantly higher in women with an anal sphincter defect compared with those with no evidence of OASIS (P = 0.018), but there was no significant difference in scores between women with an intact sphincter and those with an EAS scar only. Women with a defect had a significantly lower maximum resting pressure (median (range), 44 (8-106) vs 55 (29-86) mmHg; P < 0.001) and maximum squeeze pressure (median (range), 74 (23-180) vs 103 (44-185) mmHg; P < 0.001) compared with those in the intact group. Similar, but less marked, differences were observed in women with an EAS scar compared with those who had an intact anal sphincter. The anal length was significantly shorter in women with a defect compared with those in the intact group (median (range), 20 (10-40) vs 25 (10-40) mm; P = 0.003). Seven percent of women with a clinical diagnosis of OASIS were wrongly diagnosed. We believe that this rate may differ from that of other units but training methods and competency assessment tools for the diagnosis and repair of OASIS need urgent reappraisal. The role of EA-US in the immediate postpartum period needs further evaluation as the accurate interpretation of the images is dependent on the expertise of the staff involved. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

OP28.08: Is abnormal posterior compartment anatomy associated with anal incontinence?

It has been claimed that rectocele and intussusception are associated with anal incontinence, but this has not been studied while controlling for anal sphincter trauma. We aimed to investigate such a potential association in women with intact anal sphincter presenting with pelvic floor dysfunction. This is a retrospective study on 1314 women assessed at a tertiary urogynecological centre for pelvic floor dysfunction between 2014 and 2016. All had undergone a standardised physician-directed interview, clinical examination and transperineal 4D ultrasound (TPUS). The presence of intussusception was recorded during the examination, while descent of the rectal ampulla, rectocele, enterocele and anal sphincter trauma were measured offline. 181 women were excluded due to anal sphincter trauma (n=146) and incomplete data (n=35, leaving 1133. Mean age was 54.1 (17-89) years with mean BMI of 29.4 (15-68) kg/m2. Anal incontinence (AI) was reported by 149 (13%) patients, with a median St Mark's score (SMIS) of 12 (1-23). 638 (56%) patients had abnormal posterior compartment anatomy: 38% (n=425) showed significant descent of the rectal ampulla, 46% (n=527) a true rectocele, 8% (n=89) an enterocele and 2% (n=26) an intussusception. Table 1 shows associations between AI and these abnormalities. On adjusting for potential confounders, only the association between enterocele and AI appeared significant (OR 1.84 (1.07-3.16), p=0.026). In women without anal sphincter trauma, macroscopic anatomical abnormalities of the posterior compartment do not seem to be associated with anal incontinence, with the possible exception of enterocele.

Continence and quality of life with the modified Heitz-Boyer-Hovelacque rectal bladder for children with urinary incontinence following bladder exstrophy

Bladder exstrophy and epispadias are severe congenital anomalies associated with an open bladder and urinary sphincter. Despite modern reconstruction, there is a significant incidence of residual or recurrent urinary incontinence that impacts on quality of life (QoL) and self-esteem, which in turn limits social interaction (Figure). The present study involved 14 patients, mainly from a Middle Eastern country, and reported the early findings with a modification of the Heitz-Boyer-Hovelacque rectal bladder technique for both urinary and faecal control. Fourteen children, with a median age of 8.1 years, with poor quality of life and low self-esteem because of urinary incontinence and small polypoidal open bladders of 5-15ml volume, mostly after bladder exstrophy surgery, were managed with a modification of the Heitz-Boyer-Hovelacque rectal bladder technique keeping an intact anal sphincter. The retrorectal pulled-through colon was anastomosed to the posterior wall of the rectum just above the external sphincter complex, thereby avoiding any possible injury to the anal sphincter. All patients had a normal colon and a competent anal sphincter without lumbosacral spinal or nerve anomalies. Ten children had a 5- to 10-year follow-up, one child had a 15-year follow-up, and three others, that were also continent, were excluded because of a <5-year follow-up. There were no postoperative complications, and all were dry and odour-free by day within 2-4 weeks of surgery. Two children still had minor urinary loss at night. There were no UTIs and renal function remained unimpaired. Eleven years after surgery, one child underwent excision of a pedunculated benign inflammatory polyp from the tip of the left ureter because of recurrent torsion and bleeding, there was no recurrence at the 2-year follow-up. None of the rectal or ureteric biopsies from any of the children showed metaplasia or neoplasia; however, in view of the potential long-term risks, all children were placed on a lifelong 'proctoscopy and biopsy' protocol. The ability to be dry and odour-free, and to wear normal clothing had a striking impact on QoL and psychological well-being of the children and their families. This was reflected in their positive overall approach, voluntary school attendance, and enthusiastic participation in communal events. All agreed that their improved genital appearance markedly contributed to their better body image and increased self-esteem. These significant benefits, at a crucial time in the child's life, outweigh the potential risk of long-term neoplasia. Therefore, the Heitz-Boyer-Hovelacque rectal bladder technique is recommended with long-term proctoscopic follow-up.

Response to Loganathan et al. (2013): Prolonged pudendal nerve terminal motor latency is associated with decreased resting and squeeze pressures in the intact anal sphincter

Response to Loganathan <i>et al</i>. (2013): Prolonged pudendal nerve terminal motor latency is associated with decreased resting and squeeze pressures in the intact anal sphincter

Prolonged pudendal nerve terminal motor latency is associated with decreased resting and squeeze pressures in the intact anal sphincter

To determine the contribution of the pudendal nerve to the anal continence mechanism by determining the correlation between pudendal nerve terminal motor latency (PNTML) and resting and squeeze anal canal pressures. In all, 1051 patients were investigated with anorectal physiology studies between January 1998 and July 2010. Of these, 213 patients had intact anal sphincters on endoanal ultrasound and had undergone PNTML testing and anal manometry with measurement of resting and squeeze pressures. The relationship between PNTML and mean resting and squeeze pressures was compared in these patients with an intact anal sphincter. Values were compared using a two-sample t test with equal variances. A P value of < 0.05 was considered significant. Of these patients 40.8% had normal PNTML bilaterally, 9.9% had slow PNTML bilaterally and 21.6% had a unilateral slow PNTML. Mean resting pressure was significantly reduced in patients with unilateral slow and bilateral slow PNTML compared with normal. The magnitude of the reduction was 28% and 19% respectively. Mean squeeze pressure was significantly reduced in patients with unilateral slow and bilateral slow PNTML compared with normal. The magnitude of the reduction was 18% and 23% respectively. In patients with an intact anal sphincter, either unilaterally or bilaterally prolonged PNTMLs are associated with significantly decreased resting and squeeze pressures. Our results suggest that both internal and external sphincter function is impaired with pudendal nerve injury. The inhibition of internal sphincter function may be due to damage of autonomic, principally sympathetic fibres carried in the pudendal nerve.

Transvaginal resection of a rectal gastrointestinal stromal tumor

We herein report a case in which a rectal gastrointestinal stromal tumor (GIST) was resected transvaginally. The patient, a 45-year-old female, had a rectal GIST on the anterior wall of the lower rectum. The tumor was within 6 cm of the anal verge, a location which would normally require performing an ultra-low anterior resection using the Double Staple Technique, and a diverting stoma. To minimize the invasiveness of treatment and to reduce the postoperative morbidity, a transvaginal resection was performed. Under general anesthesia, the posterior vaginal mucosa was incised vertically. The tumor was then excised en bloc with the overlying rectovaginal septum and rectal mesenchymal tissue. The defect was repaired primarily, and a diverting stoma was not required. The procedure was uncomplicated, and the patient was discharged home with an intact anal sphincter function and no abdominal incisions. In female patients, transvaginal resection of low anterior rectal lesions may provide a minimally invasive alternative to the traditional ultra-low anterior resection.

Tu2003 Rho Kinase is the Major Molecular Pathway for the Basal Tone in Intact Human Internal Anal Sphincter (IAS) Smooth Muscle

Tu2003 Rho Kinase is the Major Molecular Pathway for the Basal Tone in Intact Human Internal Anal Sphincter (IAS) Smooth Muscle

Postpartum Traumatic Rectal Tear After Normal Vaginal Delivery with an Intact Anal Sphincter

Abstract Background: A case of “buttonhole” rectal tear after normal delivery is reported. “Buttonhole” injuries are those in which the vaginal and rectal walls are torn, causing disruption of the anal epithelium, while the external anal sphincter remains intact. Case: A 25-year-old gravida 1, para 1 who had had a normal vaginal labor 27 days earlier, was admitted, and after thorough examination, this type of injury was found. Management of the case is extensively described and a concise review of the relevant literature is presented. Results: The postoperative period was uneventful. At her next scheduled appointment, physical examination was negative for any fistula formation or surgical injuries. Conclusions: This report provides information about appropriate methods of surgical treatment and emphasizes the need for better education in cases of perineal lacerations by gynecologists. (J GYNECOL SURG 28:176)

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...

Allogenic Myoblast Transplantation in the Rat Anal Sphincter

: To determine the feasibility of injecting rat myoblasts into the intact anal sphincter as a potential treatment for anal incontinence, and to detect transferred myoblast survival and integration. : A pilot study using nonpregnant female Sprague Dawley rodents of 8 to 10 weeks of age. A biopsy of skeletal muscle was harvested from a study animal and recovered myoblasts were expanded in vitro over 10 days. Myoblasts were then tagged with a cytomegalovirus promoter to transduce green fluorescent protein (GFP) into the myoblasts. The cell aspirate was injected directly into the intact external anal sphincter using an electromyographic guidance. The animals received 1.5 or 4.5 × 10 cells of GFP-labeled myoblasts, dividing the dose between three injection sites. The remaining in vitro myoblasts were still viable 28 days post-harvest. Ten days after transplantation the anal sphincter complex was surgically extracted. : The presence of GFP-labeled myoblasts was confirmed within the external anal sphincter. : This demonstrates that myoblasts can be successfully extracted, cultivated in vitro, transplanted and will integrate into the host tissue.

Anal sphincter disruption during instrumental and non-instrumental vaginal delivery

Introduction: Anal sphincter trauma during childbirth represents the most important risk factor for development of fecal incontinence in women. Overt anal sphincter injury may be identified by clinical examination in 1-3% of vaginal deliveries, but the incidence is much higher when abnormalities are specifically sought using endoanal ultrasound and anal manometry. Aim of work: The aim of this study is to assess risk factors for sphincter damage during vaginal delivery in primiparous patients, and to assess the relationship of anal manometry and endosonography to anorectal complaints in patients who had demonstrated anal sphincter injury during vaginal delivery. Patients & methods: This was a prospective, observational study conducted over 130 healthy primiparous females with intact anal sphincter without history of either anorectal complaints or previous anorectal surgery. The patients were divided into: Group I: 100 patients without clinically recognized third- to fourth-degree intrapartum perineal tears. Group II: 15 primiparous patients who delivered by normal vaginal delivery, with clinically recognized third-degree perineal tears, who were examined following surgical repair by the overlapping technique. Group III: 15 primiparous patients who delivered by instrumental delivery, with clinically recognized third-degree perineal tears, who were examined following surgical repair. All patients were followed up by combined endoanal ultrasonography and anal manometry. Results: The risk factors for the anal sphincter damage during vaginal delivery include the length of 2nd stage if •75 min, absence of episiotomy, presence of shoulder dystocia, and the mode of delivery. In patients with anal sphincter damage, the maximal anal resting pressure (MARP) was significantly lower (P 0.05). Instrumental delivery (P<0.001), a MARP •30 mmHg (P<0.047), and ultrasound evidence of combined ES + IS defect (P=0.002), were significantly related to anorectal complaints. MASP and ultrasound evidence of an isolated EAS defect were not found to be significantly related to anorectal complaints. Conclusion: Knowledge of possible risk factors for the occurrence of anal sphincter injuries may therefore reduce the likelihood of faecal incontinence. Anal endosonography after vaginal delivery allows the diagnosis of clinically undetected anal sphincter damage that may be associated with subsequent fecal incontinence. Anal monometry is useful in assessment of anal sphincter disruption following vaginal delivery especially when combined with an endoanal ultrasonography

O299 Rectal tear with intact anal sphincter after ventouse delivery

O299 Rectal tear with intact anal sphincter after ventouse delivery

Cost–effectiveness analysis of sacral neuromodulation (SNM) with Interstim for fecal incontinence patients in Spain

ABSTRACTIntroduction: Fecal incontinence (FI) is a condition with a high impact on the psychological and social life of healthy people. Interstim, the sacral neuromodulation (SNM) therapy, has shown higher effectiveness and safety rates than surgical procedures like dynamic graciloplasty or artificial anal sphincter in patients with intact anal sphincter (IAS) and after sphincteroplasty in patients with structurally deficient anal sphincter (SDAS).Objective: To assess the cost-effectiveness of FI management in two scenarios – with and without SNM – and to estimate the potential budget impact of its progressive introduction in the Spanish setting.Methods: Two decision analytical models were developed (IAS and SDAS patients) representing the possible clinical paths for each of the scenarios (with and without SNM), as well as its clinical and economic consequences in the mid-to long term with a Markov model. Clinical and resource use data were retrieved from the literature and validated by a clinician expert panel. Effectiveness was measured with both QALYs and symptom-free years (SFY). A 3% discount rate was used for future costs and benefits (time horizon = 5 years). Prevalence figures were combined with Interstim sales forecasts to estimate the total number of patients to receive therapy over the next 5 years and the associated budget impact.Results: The introduction of Interstim in the therapeutic management of FI has an associated cost-effectiveness of €16 181 (IAS patients) and €22 195 (SDAS patients) per QALY gained. The progressive introduction of Interstim in 75 to 100 patients/year will have an estimated budget impact of 0.1% of incremental costs in patients with FI.Conclusions: Introducing Interstim in the management of FI in IAS and SDAS patients in the Spanish setting has shown to be an efficient measure with an incremental cost–effectiveness ratio below the accepted Spanish threshold (around €35 000/QALY), and with a relatively low additional cost for the Spanish NHS.

Is a morphologically intact anal sphincter necessary for success with sacral nerve modulation in patients with faecal incontinence?

Sacral nerve modulation (SNM) for the treatment of faecal incontinence was originally performed in patients with an intact anal sphincter or after repair of a sphincter defect. There is evidence that SNM can be performed in patients with faecal incontinence and an anal sphincter defect. Two groups of patients were analysed retrospectively to determine whether SNM is as effective in patients with faecal incontinence associated with an anal sphincter defect as in those with a morphologically intact anal sphincter following anal repair (AR). Patients in group A had had an AR resulting in an intact anal sphincter ring. Group B included patients with a sphincter defect which was not primarily repaired. Both groups underwent SNM. All patients had undergone a test stimulation percutaneous nerve evaluation (PNE) followed by a subchronic test over 3 weeks. If the PNE was successful, a permanent SNM electrode was implanted. Follow-up visits for the successfully permanent implanted patients were scheduled at 1, 3, 6 and 12 months and annually thereafter. Group A consisted of 20 (19 women) patients. Eighteen (90%) had a positive subchronic test stimulation. Twelve patients had a successful SNM implant during middle-term follow-up. Group B consisted of 20 women. The size of the defect in the anal sphincter varied between 17% and 33% of the anal circumference. Fourteen (70%) had a positive subchronic test stimulation. Twelve patients had a successful SNM implant during middle-term follow-up. In both groups, the mean number of incontinence episodes decreased significantly with SNM (test vs baseline: P = 0.0001, P = 0.0002). There was no significant difference in resting and squeeze pressures during SNM in group A, but in group B squeeze pressure had increased significantly at 24 months. Comparison of patient characteristics and outcome between groups A and B revealed no statistical differences. A morphologically intact anal sphincter is not a prerequisite for success in the treatment of faecal incontinence with SNM. An anal sphincter defect of <33% of the circumference can be effectively treated primarily with SNM without repair.

Light chain myeloma in a patient with thyroid carcinoma

Dear Editor, A 61-year-old woman was referred to our emergency room because of progressive back pain radiating to chest wall. Recently, she has low-grade fever and body weight loss of 4 kilograms for 2 months. She has had the histories of papillary thyroid carcinoma post thyroidectomy and iodine-131 ablative therapy 20 years ago but without following up for 1 year. Upon admission, her vital signs were stable, and body temperature was 37.8°C. Pertinent physical findings showed numbness below nipple over the trunk region and weakness over bilateral lower extremities with intact anal sphincter tone. There was neither peripheral lymphadenopathy nor hepatosplenomegaly. The complete blood cell counts revealed a white blood cell count of 9.8×10/l, a hemoglobin level of 10.3 g/dl, and a platelet count of 290× 10/l. The biochemistry revealed blood urea nitrogen 25 mg/dl, creatinine 1.1 mg/dl, calcium 10.1 mg/dl (8.1– 10.4 mg/dl), inorganic phosphorus 3.4 mg/dl, alkaline phosphatase 118 u/l, uric acid 6.6 mg/dl, lactate dehydrogenase 839 u/l, total protein 6.4 g/dl, and albumin 4.1 g/dl with an albumin to globulin (A/G) ratio of 2.2 (normal range, 1.2–2.4). Thyroid function profile included a T3 of 40.04 ng/dl (45–132 ng/dl), a thyroid-stimulating hormone of 0.1 mu/l (0.35–6.2 mu/l), a free T4 of 1.53 ng/dl (0.7– 1.8 ng/dl), and a normal thyroglobulin level. Magnetic resonance imaging (MRI) of spine showed a soft-tissue mass in the prespinal and paraspinal regions of the fourth thoracic spine (T4) causing collapse of T4 body. The bone scan of whole body reported an increased uptake on the upper part of T-spine in which metastatic tumor was presumed. She received high-dose methylprednisolone to relieve spinal compression and neurological dysfunction. Then surgical decompression with removal of spinal tumor was performed. Histopathological examination revealed plasmacytoma strongly positive for kappa light chain in tumor cells. The diagnosis of kappa light chain myeloma was affirmed by the examination of bonemarrowwhich showed normocellular marrow infiltrated by 60% of abnormal plasmacytoid cells and which stained positive for kappa light chain. Urine BenceJones protein (BJP) tests showed negative result. Serum protein electrophoresis revealed a hypogammaglobulinemia with immunoglobulin G (IgG), 368 mg/dl (751–1,560 mg/dl), IgA, 37 mg/dl (82–453 mg/dl), IgM, 24 mg/dl (46–304 mg/dl), kappa chain, 522 mg/dl (629–1,350 mg/dl), and lambda chain, 125 mg/dl (313–723 mg/dl). Urine immunoglobulin electrophoresis revealed increased kappa chain level as 668 mg/dl (normal range, 0–1.85 mg/dl). She received oral chemotherapy with mephalan (8 mg/m) plus prednisolone (60 mg/m) for 4 days combined with local radiotherapy over thoracic spines after operation. The activity of bilateral lower extremities got improved after treatment. However, febrile netropenia occurred 3 weeks after chemoradiotherapy. Rapid progressive dyspnea occurred, and chest X-ray showed diffuse interstitial infiltration over bilateral lung fields. She died of Pneumocystis carinii pneumonia (PCP) with acute respiratory distress syndrome (ARDS). Autopsy was not done. Ann Hematol (2008) 87:163–164 DOI 10.1007/s00277-007-0367-6

Predictive factors for successful sacral nerve stimulation in the treatment of faecal incontinence: a 10‐year cohort analysis

Sacral nerve stimulation (SNS) is an established treatment for faecal incontinence. We aimed to identify specific factors that could predict the outcome of temporary and permanent stimulation. A cohort analysis was performed to identify potential predictive factors in 81 patients who underwent temporary SNS at a single institution over a 10-year period (June 1996 to June 2006). Data were obtained from prospectively collected patient symptom diaries and quality of life questionnaires, operation reports, anorectal physiological studies, endoanal ultrasound images and radiology of lead placement. Clinical outcome of temporary screening was not affected by patient gender, age, body mass index, severity or length of symptoms. The need for a repeated temporary procedure was associated with subsequent failure during screening (P = 0.008). A low threshold to obtain a motor response during temporary lead insertion was associated with improved outcome (P = 0.048). Evidence of anal sphincter trauma was associated with a greater risk of failure (P = 0.040). However, there was no difference in medium-term outcome between patients with external anal sphincter (EAS) defects and patients with intact anal sphincter muscles. Variables have been identified that help to predict the outcome of SNS. The presence of an EAS defect should not preclude treatment.