Intact Anal Sphincter Research Articles

B002 Sacral Nerve Modulation for Faecal Incontinence: Repaired Anal Sphincter Complex Versus Anal Sphincter Defect

Objective Sacral nerve modulation (SNM) for the treatment of faecal incontinence (FI) was originally performed with an intact anal sphincter. Two groups of patients were analysed to investigate whether SNM is as effective in patients with FI associated with an anal sphincter defect as in patients with FI after an anal repair (AR).Method Group A was initially treated with an AR resulting in an anatomically intact anal sphincter. They were treated with SNM because of persisting or recurring FI. Group B consisted of patients with a defect in the sphincter primarily treated with SNM. The follow‐up visits were scheduled at 1, 3, 6, and 12 months and annually thereafter.Results Group A consisted of 20 patients. The mean number of incontinence episodes decreased significantly with SNM (P = 0.018). There was no significant difference in resting and squeeze pressures during SNM. Group B consisted of 20 women. The size of the defect in the anal sphincter varied between 17% and 33%. The mean number of incontinence episodes decreased significantly with SNM (P = 0.012). Again there was no significant change in the resting and squeeze pressures. Comparison between group A and B revealed no statistical difference.Conclusion Faecal incontinence associated with an anal sphincter defect of <33% of the circumference can be treated primarily with SNM.

The clinical significance of postpartum transperineal ultrasound of the anal sphincter

Background and objective To evaluate the clinical significance of postpartum anal sphincter damage by transperineal ultrasonography (TPUS) performed on the day of delivery. Methods Continence questionnaires were handed out and TPUS was performed on 154 consecutive primiparous women 6–24 h after vaginal delivery. At 2 and 6 months later, complaints and sphincteric sonographic appearance were reassessed. The puerperal women's clinical status and sonographic findings in the immediate and late postpartum period were evaluated. Results Thirty-five (23%) women complained of anal incontinence on the first postpartum day and anal sphincter damage was demonstrated by TPUS in 31 (89%) of them. Four women with anorectal complaints had an intact anal sphincter by TPUS. Follow-up questionnaires, 2 months later, revealed 30 symptomatic women: all of them had sonographically recognized tears on the initial TPUS and 27 of them had positive findings on the TPUS performed 2 months after birth. Six months after delivery, 27 women reported symptoms and all of them had sphincteric disruption evidenced on TPUS performed on the day of delivery. All the women with intact sphincter on the initial TPUS were asymptomatic 6 months later. Conclusion TPUS findings on the day of delivery are related to long-term anorectal complaints, supporting a potential role for TPUS as a screening aid for anal sphincter tears.

Anal sphincter injury after vaginal delivery in primiparous females.

The purpose of this study was to determine the incidence of anal sphincter injury and fecal incontinence after vaginal delivery. This was a prospective, descriptive, observational study conducted over a three-year period in healthy primiparous females with previously intact anal sphincter and normal continence and without history of anorectal surgery. All patients completed a continence questionnaire and underwent endoanal ultrasound four to six weeks before and six weeks after delivery. Ninety-eight primiparous females had either instrumental (vacuum or forceps) vaginal delivery (n = 23) or noninstrumental vaginal delivery (n = 75). Twenty patients, 11 (48 percent) after instrumental delivery and 9 (12 percent) after noninstrumental vaginal delivery, had clinical sphincter tears that required primary repair. Twenty-eight patients (29 percent), 19 with previously repaired sphincter injury, had ultrasonographic defects that involved the external sphincter (n = 19) or both the internal and external sphincter (n = 9). Twenty-one patients (75 percent) with ultrasonographic sphincter defects had either major (n = 5) or minor (n = 16) fecal incontinence. Anal sphincter injuries, many of them undiagnosed at the time of delivery, are common in primiparous females after vaginal delivery, especially if vacuum or forceps are used. These injuries cause fecal incontinence in a significant proportion of the patients. Patients undergoing vaginal delivery should be aware of the risks of anal sphincter injury.

STRATEGIES FOR RECONSTRUCTION AFTER UNSUCCESSFUL OR UNSATISFACTORY PRIMARY TREATMENT OF PATIENTS WITH BLADDER EXSTROPHY OR INCONTINENT EPISPADIAS

Purpose Following unsuccessful or unsatisfactory primary treatment in patients with the epispadias/exstrophy complex, the options for a surgical solution to preserve the upper urinary tract, to achieve complete continence, and to reconstruct the external and female internal genitalia are limited. We reviewed the records of the patients treated at our institution to determine a surgical compromise between ingenious operative constructions and patient desires, both of which are secondary to stabilization of renal function. Materials and Methods From 1967 to December 1997, 128 patients with bladder exstrophy/epispadias complex were treated, of 80 whom had received previous unsuccessful or unsatisfactory treatment. Of these patients 72 were followed for an average of 22.4 years after the first surgical intervention. There were 40 patients referred to our institution after primary bladder closure and bladder neck reconstruction, 10 after rectal bladder, 7 after ureterosigmoidostomy and 5 after incontinent diversion. Results At the latest followup 19 patients had a rectal reservoir, 38 an ileocecal pouch, 12 a conduit diversion and 3 an augmented Young-Dees procedure. The upper urinary tract remained stable in 95% of the renal units with rectal reservoir, 95% with ileocecal pouch, 96% with a colonic conduit and 100% with an augmented Young-Dees procedure. Day and night continence was achieved in 95% of the patients with a rectal reservoir and 97% of those with an ileocecal pouch were continent, whereas only 2 of the 3 patients with an augmented Young-Dees procedure were continent. Of the women 16 were satisfied with the cosmetic results and 6 delivered 8 children by cesarean section. Only 1 man was dissatisfied with the final cosmetic result. All adults but 1 engaged in sexual intercourse. Conclusions The first operative intervention in patients with bladder exstrophy/epispadias complex determines their fate. After failure of primary treatment, the upper urinary tract must be stabilized. In patients with severely impaired renal function the colonic conduit is our method of choice while in those with a normal or slightly dilated upper urinary tract and intact anal sphincter we performed a rectal reservoir. In the remaining patients an ileocecal pouch guarantees continence day and night. The results of genital reconstruction are satisfactory.

Gastrointestinal transit and prolonged ambulatory colonic motility in health and faecal incontinence

Background—Colonic motor function has not been studied in the ambulatory setting over a prolonged period in the unprepared state. Furthermore, the disturbance of this function in patients with faecal incontinence...

The influence of oestrogen replacement on faecal incontinence in postmenopausal women.

To assess the value of hormone replacement therapy (HRT) in postmenopausal women with faecal incontinence. Prospective observational study using a bowel function questionnaire and anorectal physiological testing before and after six months of standard oestrogen hormone replacement therapy. Menopause and colorectal clinics of two university teaching hospitals. Twenty postmenopausal women (mean age 61 years) with demonstrable faecal incontinence (mean duration 6.1 years) previously untreated with HRT. Improvement in symptoms and objective alteration in anorectal physiology tests. All women had significant symptoms of anorectal dysfunction before treatment, whereas 5/20 (25%) were asymptomatic after six months of HRT, and a further 13/20 (65%) were symptomatically improved in terms of flatus control, urgency, and faecal staining. There was no change in bowel frequency or stool consistency following HRT, but social activity was considerably improved. Anal resting pressures and voluntary squeeze increments were significantly increased following oestrogen therapy, although no differences in anal canal vector symmetry index were observed. Insignificant changes occurred in threshold volume of rectal sensation and volume of defaecatory urge, but there was a significant change in maximum tolerated rectal volume after six months. Neither anal canal electrosensitivity nor pudendal nerve terminal motor latency was altered following HRT. Seven of the 20 women (35%) had an identifiable anal sphincter defect on anal endosonography. Statistical analysis, however, showed no significant difference in outcome in this group compared with those with an intact anal sphincter. A larger population sample may demonstrate this. This observational study has shown a possible benefit of oestrogen replacement in postmenopausal women with symptoms of impaired faecal continence. A prospective randomised controlled trial is now advisable to test this hypothesis.

Avoidance of anastomotic complications in low anterior resection of the rectum.

This retrospective study was designed to evaluate the efficacy of suction-irrigation drainage systems in reducing anastomotic complications. The current trend for lesions of the upper and middle rectum emphasizes maintaining an intact anal sphincter mechanism as long as limits of resection are not compromised. Removal of the rectosigmoid colon with an anastomosis below the peritoneal reflection accomplishes this goal but with appreciable morbidity and mortality, which is in great part related to subsequent anastomotic breakdown and resultant pelvic abscess and fecal fistula formation. The presence of collections of blood, serum, and cellular debris contribute significantly to anastomotic disruption by serving as a culture medium in which bacteria may thrive, leading to abscess formation with subsequent deleterious effects on the integrity of the adjacent low lying anastomosis. Many surgeons accepted this risk and routinely performed diverting colostomies to minimize the consequences of anastomotic disruption below the peritoneal reflection. The authors felt that if this risk could be sufficiently reduced, it would obviate the need for a protecting stoma. From 1980 to 1988, 60 consecutive patients were subjected to anterior or low anterior resections in which a closed Shirley sump irrigation system was used to facilitate postoperative drainage of the pelvis and thus avoid hematoma formation. Since this original study group of 60 patients, another 100 consecutive patients have been entered into this study. This cohort group again consisted of patients with lesions of the upper, middle, and lower rectum who underwent anterior or low anterior resections of the rectum. Fifty-three of the original 60 patients did not have protecting stomas. Clinical leak rate for this series was 1.67 percent. Clinical leak rate for this updated series of 100 patients was 1 percent, with overall clinical leak rate of 1.25 percent in 160 consecutive patients. There were no deaths in the series, and overall morbidity was 7.5 percent. The authors felt that removing blood, serum, and cellular debris from the pelvis following resections of all or part of the rectum minimizes the risk of anastomotic disruption. With this routine, covering colostomies are no longer required for most patients undergoing anterior or low anterior resections of all or part of the mesorectum.

Presentation of foot through intact anus during breech delivery

0 NE of the most startling birth injuries that has occurred during my practice was a laceration of the rectum with presentation of a foot through an intact anal sphincter, during the course of an apparently normal breech delivery. DeLee,l in his text, mentions that “there have been cases where the rectovaginal septum gives way over the advancing presenting part, head, arm, or breech, and the latter appears at the anus. ” A review of the literature reveals several cases. Leroux* reports expulsion of a massive ovarian cyst through the rectum, after laceration of the rectum in the course of labor. Yussufs reports rupture of a retrouterine hematocele into the rectum with passage of a fetus per rectum. In 1934, Hein described in an apparently normal primiparous delivery, the appearance of the anterior leg vaginally, with the posterior leg presenting through the intact anus so that the child was ( ( literally riding on the perineum. ’ ’ Later in the same year, Pohl5 described an almost identical case. Kassebohm and Schreibere report two cases of delivery complicated by rectal stricture in which rupture of the rectum occurred during the course of delivery. Both of these lacerations were apparently not detected at the time of delivery, and both patients died; in the other cases, recognized and appropriately treated, the patients made uneventful and complete recoveries. Pate17 writes of a gravida ii who delivered spontaneously through the rectum, the cervix opening into the rectum. He concluded that the first delivery had also taken place through the rectum. Preston6 saw a Kikuyu woman who had delivered a stillborn child through the rectum three days previously. The apparent cause for rectal delivery in this case was the presence of massive keloid growths around the vagina resulting from circumcision, and almost obliterating the vaginal orifice. This patient died of sepsis. Perry9 reports delivery of a dead fetus, apparently an ectopic pregnancy, through the rectum. The cervix was virginal, and three months later there was fullness in the right fornix which was considered the site of the extrauterine pregnancy. Findleylo and Young11 report similar cases, the former describing the protrusion through the anus of first the right hand and arm, then the left hand during the course of a low forceps delivery (left occipitoanterior position). In the. latter case, the right foot pushed through the rectal mucosa and appeared through the anus. It is surprising that except in those cases in which there was previous rectal or vaginal damage, the outcome for the mother was good. The methods of handling the cases varied. Usually, the bridge of anus and perineum was severed prior to completion of delivery of the infant. In one case, the foot appearing at the rectum was pushed into the vagina and delivery accomplished. In some cases the rent, which was clean cut and almost bloodless, was repaired in layers. In others the defect was merely packed. Aftercare varied; in some cases the bowels were moved early; in others the bowels were “locked” for a week. Mrs. M. S., a white woman, aged 30 years, was first seen in the office on May 10, 1946. The date of thk last menstrual period was March 15, 1946. The physical examination revealed a normal healthy white woman. The past history was not significant. There had been one miscarriage on Jan. 13, 1946, at two and one-half months, cause undetermined. The external measurements were normal. It was later determined that a multiple (twin) pregnancy existed. The patient gained 20% pounds during her pregnancy.