Internal Anal Sphincter Defects Research Articles

Overt Rectal Prolapse and Fecal Incontinence

Rectal prolapse is frequently associated with fecal incontinence; however, the relationship is questionable. The study was designed to evaluate fecal incontinence in a large consecutive series of patients who suffered from rectal prolapse, focusing on both past history, anal physiology, and imaging. Eighty-eight consecutive patients who suffered from an overt rectal prolapse (72 women, 16 men; mean age, 51.1 +/- 19.5 years) as a main symptom were analyzed; 48 patients also experienced fecal incontinence compared with 40 without incontinence. Logistic regression analyses were performed. The two groups of patients did not differ with respect to parity, weekly stool frequency, main duration of symptoms before referral, occurrence of dyschezia, and digital help to defecate. Patients with prolapse who were older than 45 years (odds ratio (OR), 4.51 (1.49-13.62); P = 0.007) and those with a past history of hemorrhoidectomy (OR, 9.05 (1.68-48.8); P = 0.01) were significantly more incontinent. Incontinent group showed frequent internal anal sphincter defect compared with the continent group (60 vs. 6.2 percent; P = 0.0018). In patients with overt rectal prolapse, the occurrence of fecal incontinence needs special consideration for age and previous hemorrhoid surgery as causative factors. Anal weakness and sphincter defects are frequently observed.

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.

Delivery method, anal sphincter tears and fecal incontinence: new information on a persistent problem

To review the risk factors for anal sphincter tears during vaginal delivery and their association with fecal incontinence symptoms. Recent evidence links sphincter tears with fecal incontinence, which has a significant negative impact on quality of life. The Childbirth and Pelvic Symptoms cohort study reported that the incidence and severity of fecal incontinence was increased in primiparous women experiencing a sphincter tear. Risk factors for tear included forceps, occiput posterior, vacuum delivery, prolonged second stage of labor and epidural. Using cesarean delivery to prevent fecal incontinence has not been justified, but the confluence of these risk factors in the context of labor management may be important in deciding on earlier intervention with cesarean delivery. Internal anal sphincter defects impact fecal incontinence, highlighting the identification and repair of the internal anal sphincter for future research and clinical applications. Routine episiotomy (or instrumentation) is not warranted, and there is no clear advantage to mediolateral episiotomy or overlapping sphincter repair. Postpartum ultrasound of the sphincter complex may have an emerging role. The modifiable risk factors of routine episotomy and instrumented delivery are associated with sphincter tear; definitive recommendations for labor management remain unclear in preventing fecal incontinence.

Novos tratamentos para a incontinência anal: injeção de silicone melhora a qualidade de vida em 35 pacientes incontinentes

Demonstrar através do índice de incontinência e de um instrumento de qualidade de vida, o benefício da utilização do silicone como substância de preenchimento para o tratamento da incontinência anal. 35 pacientes incontinentes foram avaliados através do índice de incontinência (Cleveland Clinic Florida Scoring System-CCFSS) e instrumento de qualidade de vida (Fecal Incontinence Quality of Life-FIQL), antes e após injeção ambulatorial trans-esfincteriana de silicone. Os critérios de inclusão foram: incontinência anal associada a defeito simples do esfíncter interno ou associado a pequeno defeito do esfíncter externo em quadrante anterior. A escala de qualidade de vida avaliada inclui quatro domínios: depressão, estilo de vida, comportamento e constrangimento. Após 3 meses de tratamento, todos os pacientes foram reavaliados através do índice de incontinência e instrumento de qualidade de vida. Os resultados foram analisados estatisticamente através do programa GraphPd Instat. 28 mulheres e 7 homens com idade média de 60,3 (19-80) anos foram submetidos a injeção de silicone para o tratamento de incontinência anal. O índice médio de incontinência, antes e após a injeção, foi de 11,3 e 4,3 (p&lt;0.001). Em relação às alterações na escala de qualidade de vida, notamos significantes alterações em todos os domínios estudados antes e após a injeção: (1) estilo de vida p&lt;0,0001;(2)comportamento p&lt;0,0001;(3) depressão p&lt;0,0001; (4) constrangimento p&lt;0,0001. Em casos selecionados, a injeção trans-esfincteriana de silicone proporciona uma melhora do quadro de incontinência anal, observada pela mudança significativa dos parâmetros do índice de incontinência e instrumento de qualidade de vida.

Internal anal sphincter defect influences continence outcome following obstetric anal sphincter injury

To date, little correlation has been found between the extent of anal sphincter injury defined by endoanal ultrasound and symptoms of postpartum fecal incontinence. To define this relationship, we assessed a large cohort of women following first recognized obstetric anal sphincter injury. In all, 500 consecutive women were studied at 3 months following primary repair of a first recognized obstetric anal sphincter injury sustained during vaginal delivery. Assessment included a standardized fecal incontinence questionnaire (modified Jorge-Wexner score), anal manometry, and endoanal ultrasound. Severe fecal incontinence was defined by a score greater than 9. Statistical significance of the relationship between symptoms and factors including age, parity, mode of delivery, and extent of sphincter injury (defined by endoanal ultrasound), was analyzed through multiple logistic regression. Increasing age (P = .006) and parity (P = .039), instrumental delivery (P < .001), an anal canal resting pressure of < or = 35 mm Hg (P = .047), and internal anal sphincter (IAS) injury (P = .002) were significantly related to the presence of fecal incontinence. With multivariate analysis, and adjusting for other factors, instrumental delivery (OR 3.1; 95% CI 1.2-7.9) and IAS defect thickness (partial thickness defect > 1 quadrant or full thickness defect; OR 5.1 95% CI 1.5-22.9) were predictive of severe incontinence, but external anal sphincter defects were not. Endosonographic evidence of IAS injury is predictive of fecal incontinence following obstetric anal sphincter injury. The presence of an IAS defect should be sought carefully if the anal sphincter is injured during vaginal delivery.

Do internal anal sphincter defects decrease the success rate of anal sphincter repair?

Anatomic anal sphincter defects can involve the internal anal sphincter (IAS), the external anal sphincter (EAS), or both muscles. Surgical repair of anteriorly located EAS defects consists of overlapping suture of the EAS or EAS imbrication; IAS imbrication can be added regardless of whether there is IAS injury. The aim of this study was to assess the functional outcome of anal sphincter repair in patients intraoperatively diagnosed with combined EAS/IAS defects compared to patients with isolated EAS defects. The medical records of patients who underwent anal sphincter repair between 1988 and 2000 and had follow-up of at least 3 months were retrospectively assessed. Fecal incontinence was assessed using the Cleveland Clinic Florida incontinence score wherein 0 equals perfect continence and 20 is associated with complete incontinence. Postoperative scores of 0-10 were interpreted as success whereas scores of 11-20 indicated failure. A total of 131 women were included in this study, including 38 with combined EAS/IAS defects (Group I) and 93 with isolated EAS defects (Group II). Thirty-three patients (87%) in Group I had imbrication of a deficient IAS, compared to 83 patients (89%) in Group II. All patients had either overlapping EAS repair (n=121) or EAS imbrication (n=10). Mean follow-up was 30.9 months (range, 3-131 months). There were no statistically significant differences between the two groups relative to age (48.3 vs. 53.0 years; p=0.14), preoperative incontinence score (16.1 vs. 16.7; p=0.38), extent of pudendal nerve terminal motor latency pathology (left, 11.1% vs. 8%; p=0.58; right, 8.6% vs. 15.1%; p=0.84), extent of pathology at electromyography (54.8% vs. 60.1%; p=0.43), and length of follow-up (26.9 vs. 32.5 months; p=0.31). The success rates of sphincter repair were 68.4% for Group I versus 55.9% for Group II (p=NS). Both groups were well matched for incidence of IAS imbrication as well as age, follow-up interval, and physiologic parameters. The success rates of anal sphincter repair were not statistically significant between the two groups. A pre-existing IAS defect does not preclude successful sphincteroplasty as compared to repair of an isolated EAS defect. Thus, patients with combined anal sphincter defects should not be considered as poor candidates for sphincter repair.

The utility of endovaginal sonography in the evaluation of fecal incontinence

OBJECTIVE The endoanal sonography in female patients with faecal incontinence is sometimes difficult and can lead to diagnostic errors. The aim of this study is to evaluate the value of endovaginal sonography in such cases. MATERIAL AND METHOD Thirty female patients complaining of faecal incontinence are included in the study. Anal endosonography was performed in all of them in a single ambulatory session, pictures were taken from all along the anal and results were analyzed afterward. Vaginal endosonography was then performed using the same equipment. Result from both techniques were compared. RESULTS Endoanal sonography was performed in all 30 patients. In 17 cases no anomalies were found. In 3 patients a simple internal anal sphincter defect was found. One case showed a lateral lesion in both sphincters. Six cases presented anterior external defect and in the rest 3 cases a clear view of the anterior wall was impossible. Vaginal endosonography shows a clear image of the anal canal in 23 out of 30 patients. In two cases changed the results of anal endosonography. CONCLUSION In the study of faecal incontinence, despite of its technical limitations, endovaginal ultrasound could be of help when the anterior wall of the anal canal is not properly defined.

Anal Sphincter Defects in Patients with Fecal Incontinence: Endoanal versus External Phased-Array MR Imaging

To prospectively compare external phased-array magnetic resonance (MR) imaging with endoanal MR imaging in depicting external and internal anal sphincter defects in patients with fecal incontinence and to prospectively evaluate observer reproducibility in the detection of external and internal anal sphincter defects with both MR imaging techniques. The medical ethics committees of both participating hospitals approved the study, and informed consent was obtained. Thirty patients (23 women, seven men; mean age, 58.7 years; range, 37-78 years) with fecal incontinence underwent MR imaging with both endoanal and external phased-array coils. MR images were evaluated by three radiologists with different levels of experience for external and internal anal sphincter defects. Measures of inter- and intraobserver agreement of both MR imaging techniques and of differences between both imaging techniques were calculated. Both MR imaging techniques did not significantly differ in the depiction of external (P > .99) and internal (P > .99) anal sphincter defects. The techniques corresponded in 25 (83%) of 30 patients for the depiction of external anal sphincter defects and in 28 (93%) of 30 patients for the depiction of internal anal sphincter defects. Interobserver agreement was moderate to good for endoanal MR imaging and poor to fair for external phased-array MR imaging. Intraobserver agreement ranged from fair to very good for both imaging techniques. External phased-array MR imaging is comparable to endoanal MR imaging in the depiction of clinically relevant anal sphincter defects. Because of the weak interobserver agreement, both MR imaging techniques can be recommended in the diagnostic work-up of fecal incontinence only if sufficient experience is available.

Integrity of the Anal Sphincters After Pouch-Anal Anastomosis: Evaluation With Three-Dimensional Endoanal Ultrasonography

The aim of the present study was to assess the integrity of the anal sphincters after handsewn pouch-anal anastomosis performed with the help of a Scott retractor. For this purpose the anal sphincters were visualized with three-dimensional endoanal ultrasonography. Patients undergoing a colonic pouch-anal anastomosis or an ileal pouch-anal anastomosis were included. Before and six months after the procedure, the length and volume of both sphincters were assessed with three-dimensional endoanal ultrasonography, and anal manometry was performed. Continence scores were determined using the Fecal Incontinence Severity Index (FISI). Fifteen patients with a colonic pouch and 13 patients with an ileal pouch were examined. Six months after the procedure, three-dimensional endoanal ultrasonography showed significant alterations of the internal anal sphincter in eight patients with a colonic pouch-anal anastomosis (53 percent) and in eight patients with an ileal pouch-anal anastomosis (62 percent). These alterations were characterized by asymmetry or thinning. No defects were seen in the colonic pouch group, but, in two patients with an ileal pouch, a small defect in the internal anal sphincter was found. A decrease in internal anal sphincter volume was seen only in patients with a colonic pouch-anal anastomosis (P = 0.009). In both groups the length of the internal anal sphincter and the length, thickness, and volume of the external anal sphincter remained the same. After the procedure a reduction of maximum anal resting pressure was found in both groups (colonic pouch: P < 0.001, ileal pouch: P = 0.001). Maximum anal squeeze pressure was reduced in only patients with an ileal pouch-anal anastomosis (P = 0.006). The observed alterations of the internal anal sphincter and the manometric findings showed no correlation with the postoperative Fecal Incontinence Severity Index scores. Handsewn pouch-anal anastomosis, performed with the help of a Scott retractor, only rarely leads to internal anal sphincter defects, but three-dimensional endoanal ultrasonography shows alterations of the internal anal sphincter in 57 percent of the patients. No correlation was observed between these alterations and the functional outcome.

The utility of endovaginal sonography in the evaluation of fecal incontinence

The endoanal sonography in female patients with faecal incontinence is sometimes difficult and can lead to diagnostic errors. The aim of this study is to evaluate the value of endovaginal sonography in such cases. Thirty female patients complaining of faecal incontinence are included in the study. Anal endosonography was performed in all of them in a single ambulatory session, pictures were taken from all along the anal and results were analyzed afterward. Vaginal endosonography was then performed using the same equipment. Result from both techniques were compared. Endoanal sonography was performed in all 30 patients. In 17 cases no anomalies were found. In 3 patients a simple internal anal sphincter defect was found. One case showed a lateral lesion in both sphincters. Six cases presented anterior external defect and in the rest 3 cases a clear view of the anterior wall was impossible. Vaginal endosonography shows a clear image of the anal canal in 23 out of 30 patients. In two cases changed the results of anal endosonography. In the study of faecal incontinence, despite of its technical limitations, endovaginal ultrasound could be of help when the anterior wall of the anal canal is not properly defined.

Can three-dimensional endoanal ultrasonography detect external anal sphincter atrophy? A comparison with endoanal magnetic resonance imaging

Anal sphincter atrophy is associated with a poor clinical outcome of sphincter repair in patients with faecal incontinence. Preoperative assessment of the sphincters is therefore relevant. External anal sphincter (EAS) atrophy can be detected by endoanal magnetic resonance imaging (MRI), but not by conventional endoanal ultrasonography (EUS). Three-dimensional EUS allows multiplanar imaging of the anal sphincters and thus enables more reliable anal sphincter measurements. The aim of the present study was to establish whether 3D EUS measurements can be used to detect EAS atrophy. For this purpose 3D EUS measurements were compared with endoanal MRI measurements. Patients with symptoms of faecal incontinence underwent 3D EUS and endoanal MRI. Internal anal sphincter (IAS) and EAS defects were assessed on 3D EUS and endoanal MRI. EAS atrophy was determined on endoanal MRI. The following measurements were performed: EAS length, thickness and area. Furthermore, EAS volume was determined on 3D EUS and compared with EAS thickness and area measured on endoanal MRI. Eighteen parous women (median age 56 years, range 32-80) with symptoms of faecal incontinence were included. Agreement between 3D EUS and endoanal MRI was 61% for IAS defects and 88% for EAS defects. EAS atrophy was seen in all patients on endoanal MRI. Correlation between the two methods for EAS thickness, length and area was poor. In addition, correlation was also poor for EAS volume determined on 3D EUS, and EAS thickness and area measured on endoanal MRI. Three-dimensional EUS and endoanal MRI are comparable for detecting EAS defects. However, correlation between the two methods for EAS thickness, length and area is poor. This is also the case for EAS volume determined on 3D EUS and EAS thickness and area measured on endoanal MRI. Three-dimensional EUS can be used for detecting EAS defects, but no 3D EUS measurements are suitable parameters for assessing EAS atrophy.

Importance of evacuatory disturbance in evaluation of faecal incontinence after third degree obstetric tear

To correlate anorectal function including rectal evacuation with anorectal physiology and endoanal ultrasound in women with third degree obstetric anal sphincter injury repaired at the time of delivery. Forty-four women with repaired third degree tears underwent anorectal physiology, anal ultrasonography and clinical assessment using the St. Marks incontinence score (0-24). Evacuatory disturbance was assessed by questionnaire. There was a significant correlation between disturbed evacuation and incontinence symptoms (P=0.030). There was also a significant correlation between disturbed evacuation and internal anal sphincter (IAS) injury (P=0.026), but there was no correlation with external anal sphincter (EAS) injury. There was a correlation between disturbed evacuation and low resting anal pressure (P=0.013). Although IAS defects were associated with low anal pressure, only the correlation with Maximum Squeeze Pressure reached statistical significance (P=0.018). Women with evacuatory disturbance after repaired third degree tears have a greater level of incontinence than those whose emptying is normal. This association is related to internal sphincter injury and reduced anal sphincter pressures.

Anal endosonography in patients with anorectal symptoms after haemorrhoidectomy.

Anorectal symptoms after haemorrhoidectomy are common and treatment is often empirical. Because of this, an audit was carried out of the value of anal endosonography in patients with anorectal symptoms after haemorrhoidectomy. Between May 1993 and February 1997, 16 patients (ten men and six women of median age 56 (range 35-77) years) were investigated by anal endosonography for anorectal symptoms after haemorrhoidectomy which involved anorectal incontinence (n = 10), anal pain (n = 4) and obstructive defaecation (n = 2). The findings were compared with those in a matched group of asymptomatic patients after haemorroidectomy. Anal endosonography demonstrated an abnormality in 12 symptomatic patients. Of the ten patients with anorectal incontinence, endosonography showed an internal anal sphincter defect (n = 5), a combined sphincter defect (n = 2) and an isolated external anal sphincter defect (n = 1). Normal appearances were seen in all asymptomatic patients. The endosonographic abnormalities of the four patients with anal pain included internal anal sphincter defect (n = 1), extrinsic mass (n = 1), and intersphincteric abscess (n = 1). One of the two patients with obstructive defaecation had an isolated external anal sphincter defect on endosonography. These results show a high yield of endosonographic abnormalities in patients who experience symptoms after haemorrhoidectomy. In particular, occult sphincter injury as a cause of incontinence in these patients can frequently be demonstrated.

Frequency of operative trauma to anal sphincters: evaluation with endoanal ultrasound.

Sphincter trauma after anorectal surgery is usually asymptomatic. Frequency of trauma cannot be established with the clinical examination only. The frequency of operative sphincter defects and their correlation with disorders of continence was evaluated with the endoanal ultrasound. This study includes 123 subjects who had undergone anorectal surgery in the past and were examined with endoanal ultrasound for various indications such as continence disorders, recurrent fistula, idiopathic perineal pain, or simple postoperative follow-up. No subjects had isolated external anal sphincter defects. Nineteen of 123 patients (15%) had minor or major continence disorders, 55 patients (45%) had no sphincter defects, 42 (34%) had only internal anal sphincter (IAS) defects, and 26 (21%) had simultaneously external and internal anal sphincter (EAS) defects. The incidence of IAS and EAS trauma after Milligan-Morgan hemorrhoidectomy was 1/18 (5.5%) and 0/18 respectively; after fistula repair, 24/42 (57%) and 12/42 (29%); and after anal dilatation, 13/17 (76%) and 4/17 (24%). Sixteen of 26 patients (62%) with EAS trauma and 51/68 patients (75%) with IAS trauma did not report any disorders of continence. In patients with two or more operations, the frequency of IAS trauma was 74%, 30% for EAS trauma, and 26% for continence disorders.

Colorectal 25

To assess anal sphincter structure and functional outcomes following third-degree perineal tears and the effect of its disruption on the development of anal incontinence. Fifty-one consecutive patients, 41 primigravidae and 10 multigravidae, with third-degree intrapartum perineal tears, primarily repaired, were recruited 4 months postpartum. Patients completed questionnaires assessing faecal incontinence. Anal manometry and endosonography were then performed. No patient reported incontinence prior to pregnancy. The incidence of faecal incontinence was 12 per cent. Six patients were incontinent of faeces and 10 incontinent of either flatus and/or fluid. Eighty-one per cent of anal incontinent patients were primigravidae (OR 0.96). Three women had previous third-degree tears, with one anal incontinence on subsequent delivery. Disruption of the external anal sphincter (EAS) was identified endosonographically in 26 patients. In 13 patients, there was an associated internal anal sphincter (IAS) defect. Clinically unsuspected tears of the Anal sphincter mechanism were diagnosed by anal endosonography in 46 per cent of asymptomatic patients. The EAS alone was involved in 14, IAS in three, and both in five patients. Clinical examination of women with anal incontinence identified an anal sphincter defect in 46 per cent. Ultrasound in anal incontinent patients showed an IAS defect in 42 per cent and an EAS defect in 52 per cent. All patients with faecal incontinence had a disruption of the EAS identified by endosonography (P < 0.05). No significant relationship was demonstrated between symptoms and anal manometry (P = 1.0, n.s.). Third-degree tears cause significant, although clinically unsuspected anal sphincter defects. It may be that anal manometry alone is not sufficient to exclude sphincter injury.

Anal endosonography for assessment of anal incontinence with a linear probe: relationships with clinical and manometric features.

This study determined correlations of clinical and manometric features with those of anal endosonography (AES). Between 1996 and 1999 we examined 58 patients suffering from anal incontinence (AI) by AES using a linear probe and anorectal manometry following a standardized protocol. Twelve of the 58 patients (21%) had a history of anal surgery. Of the 40 women who had under-gone at least one vaginal delivery 22 (55%) sustained an obstetric tear and 12 (30%) required forceps for delivery. A perineal descent was observed in 24 of 32 women with AI (75%) and urinary incontinence in 24 of 44 (54%). An anal sphincter defect was diagnosed in 45 of the 58 patients (77%). The internal anal sphincter defects occurring in 42 patients (72%) were significantly associated with a decrease in the resting anal pressure. The external anal sphincter defects occurring in 33 patients (57%) were significantly associated with a decrease in the voluntary anal contraction. Considering AES and manometric findings, a good correlation was observed between internal sphincter defect and the resting anal pressure and between external sphincter defects and the voluntary anal contraction. AI is usually associated with a global perineal insufficiency requiring special attention in terms of both training and medical management.

Results of sphincteroplasty in 86 patients with anal incontinence.

This study was designed to analyze critically the short-term and long-term outcome of sphincteroplasty and to identify high-risk factors. Eighty-six patients with fecal incontinence associated with an ultrasound defect of the external anal sphincter were treated by anal sphincteroplasty. Clinical and physiologic assessment was made before surgery, and clinical evaluation was made three months and an average of 40 months after surgery. The evaluation of 86 patients three months after surgery showed that 42 patients were totally continent (49 percent), 28 were incontinent for gas (33 percent), and 16 still had fecal incontinence (19 percent). Seventy-four patients (86 percent) were contacted 40 months after surgery. Twenty-one patients (28 percent) were totally continent, 17 were incontinent to gas (23 percent), and 36 were incontinent to feces (49 percent). Forty-six percent of patients felt they were clearly improved after surgery. Poor results were associated with an internal anal sphincter defect. Our study suggests that in the long term, one-third of patients are totally continent after sphincteroplasty. One-half of patients are satisfied, but only if their incontinence to feces has totally disappeared. Results of sphincteroplasty deteriorate with time. One factor in poor prognosis is the presence of an associated defect of the internal anal sphincter.

Outcome of biofeedback for faecal incontinence.

Biofeedback has been reported to improve or eliminate symptoms in approximately 70 per cent of patients with faecal incontinence. However, it is unknown which patients respond in relation to the different symptomatic types of faecal incontinence and the different structural sphincter aetiologies. One hundred consecutive patients (84 women; median age 49 years) who completed biofeedback treatment were prospectively characterized by symptoms and by structural integrity of the internal and external anal sphincters as assessed endosonographically (87 patients). Patients underwent a median of 4 biofeedback sessions. Overall, 43 of the 100 patients regarded themselves as symptomatically cured and 24 improved after treatment. Cure or improvement was experienced by 24 of 30 patients with a structurally normal anal sphincter, by 27 of 46 patients with an external anal sphincter structural defect, and by seven of 11 with an isolated internal anal sphincter defect or atrophy. Thirty-three of 60 patients with urge incontinence alone were symptomatically cured, compared with five of 22 of those with only passive incontinence. Biofeedback retraining is effective in the short term in treating a majority of patients with faecal incontinence. It is most successful in treating urge incontinence, but also helps some patients with passive leakage. Even in patients with structural anal sphincter damage, some symptom improvement or cure is achieved.

Transvaginal sonography of the anal sphincter: reliable, or not?

The purpose of this study was to validate the use of transvaginal sonography for anal sphincter evaluation, compare this technique with the more commonly used transanal technique, and explain a publication that suggested that transvaginal sonography is unreliable. The study population consisted of 50 women, of whom 44 prospectively underwent transanal and transvaginal sonography. The six remaining patients with surgical confirmation underwent only transvaginal sonography. All images were interpreted by the examining radiologist and then reviewed by a second radiologist who was unaware of the first radiologist's interpretations. Defects in the external and internal anal sphincters, the status of the perineal body, and any perianal collections or fistulas were documented. Twenty-five of the 50 patients showed sphincteric defects. Twenty-two had a defect in the external anal sphincter, of whom 16 had a matching internal anal sphincter defect. Four patients had an isolated internal anal sphincter defect. Surgery in nine of these 22 patients confirmed the defects seen on sonography. The 10th patient who underwent surgery had scar tissue rather than a tear in the external anal sphincter that corresponded with the defect seen on sonography. Defects were identified in all patients presenting with fecal incontinence who had undergone either a primary repair or an anterior sphincteroplasty. Of the 25 patients with intact sphincters on both transvaginal and transanal sonography, four had other significant findings including two perianal abscesses and two T3 rectal carcinomas. In 40 of the 44 patients who were prospectively imaged using both techniques, the sonographic findings were in agreement. Review, performed by a second radiologist who was unaware of the first radiologist's interpretations, verified the findings resulting in an 88.6% interobserver agreement. In all patients, perineal body assessment and assessment of perianal inflammatory disease was more accurate with the transvaginal technique. Transvaginal sonography is a reliable method for evaluating the anal sphincter, with an accuracy equivalent to that of the transanal technique. Transvaginal sonography is preferable for evaluation of the perineal body and perianal inflammatory processes.

Endosonographic evidence of injury to the internal anal sphincter after low anterior resection: long-term follow-up.

Transanal stapled anastomosis has been associated with continence disturbances and reduced postoperative anal sphincter function. The aim of the present work was to study the effect of transanal stapling on anal sphincter morphology by endoanal ultrasound. Thirty-nine consecutive patients undergoing stapled low anterior resection for rectal carcinoma were assessed. Each patient was assessed by endoluminal ultrasound before surgery, immediately after surgery, and at 3, 6, 9, 12, and 24 months after surgery. There were no preoperative internal anal sphincter defects observed. Three female patients were observed to have preoperative evidence of external anal sphincter defects. After low anterior resection, seven patients were found to have internal anal sphincter defects, which persisted after the two-year follow-up. There were no additional external anal sphincter injuries. Three patients with internal anal sphincter injuries required the use of pads for poor bowel function. Up to 18 percent of patients who underwent stapled low anterior resection had long-term evidence of internal anal sphincter injury. The external sphincter does not appear to be affected by the procedure.