Rate Of Anal Incontinence Research Articles

Moderate or intensive management of the active phase of second-stage labor and risk of urinary and anal incontinence: results of the PASST randomized controlled trial

Incontinence occurs frequently in the postpartum period. Several theoretical pathophysiological models may underlie the hypothesis that different types of management of the active phase of the second stage of labor have different effects on pelvic floor muscles and thus perhaps affect urinary and anal continence. This study aimed to evaluate the impact of "moderate pushing" on the occurrence of urinary or anal incontinence compared with "intensive pushing," and to determine the factors associated with incontinence at 6 months postpartum. This was a planned analysis of secondary objectives of the PASST (Phase Active du Second STade) trial, a multicenter randomized controlled trial. PASST included nulliparous women with singleton term pregnancies and epidural analgesia, who were randomly assigned at 8 cm of dilatation to either the intervention group that used "moderate" pushing (pushing only twice during each contraction, resting regularly for 1 contraction in 5 without pushing, and no time limit on pushing) or the control group following the usual management of "intensive" pushing (pushing 3 times during each contraction, with no contractions without pushing, with an obstetrician called to discuss operative delivery after 30 minutes of pushing). Data about continence were collected with validated self-assessment questionnaires at 6 months postpartum. Urinary incontinence was defined by an ICIQ-UI SF (International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form) score ≥1 and anal incontinence by a Wexner score ≥2. A separate analysis was also performed among the more severely affected women (ICIQ-UI SF ≥6 and Wexner ≥5). Factors associated with incontinence were assessed with univariate and multivariable analyses. Among 1618 women initially randomized, 890 (55%) returned the complete questionnaire at 6 months. The rate of urinary incontinence was 36.6% in the "moderate" pushing group vs 38.5% in the "intensive" pushing group (relative risk, 0.95; 95% confidence interval, 0.80-1.13), whereas the rate of anal incontinence was 32.2% vs 34.6% (relative risk, 0.93; 95% confidence interval, 0.77-1.12). None of the obstetrical factors studied related to the second stage of labor influenced the occurrence of urinary or anal incontinence, except operative vaginal delivery, which increased the risk of anal incontinence (adjusted odds ratio, 1.50; 95% confidence interval, 1.04-2.15). The results of the PASST trial indicate that neither moderate nor intensive pushing efforts affect the risk of urinary or anal incontinence at 6 months postpartum among women who gave birth under epidural analgesia.

The long-term prevalence of anal incontinence in women with and without obstetric anal sphincter injuries

Introduction:Anal incontinence (AI) is a distressing and common condition for women. Women who sustain obstetric anal sphincter injuries (OASI) have been reported to have a higher prevalence of long-term AI than those who do not. However, the data is wide ranging, inconsistent and seldom comparative, with rates quoted varying between 13.1% and 74%. Methods:139 women who sustained OASI at their first delivery and 44 women who did not (controls) were contacted at 6 weeks and then a mean of 8 years following their first delivery. They were asked to complete a questionnaire including the St Mark’s Incontinence Score (SMIS) to assess the prevalence and severity of anal incontinence. Results:There was a high prevalence of anal incontinence (SMIS ≥1) in both women with OASI (62%) and controls (59%) (NS). The prevalence of severe AI (SMIS ≥ 6) was 27% in the OASI group and 18% in controls (NS). Higher grade tears and operative delivery were associated with higher rates of severe AI. In women with OASI, the mode of subsequent delivery did not impact the prevalence of AI. Conclusion:Women with OASI have a similar prevalence of long-term AI compared with women who do not sustain OASI. Some degree of AI is common 8 years post-partum, with our study demonstrating a high prevalence of 59% in controls. Brief summary:Women with and without OASI were contacted 5–15 years post-partum, and there was no difference in the rates of anal incontinence between the two groups.

A Video-Assisted Anal Fistula Treatment (VAAFT): A New Minimally Invasive Treatment Option for Fistula in Ano

Objective: To determine the outcome of video-assisted anal fistula treatment (VAAFT): A new minimally invasive treatment option for fistula in ano.
 Study Design: This is an observational study.
 Setting: Study carried out at General Surgery department, Liaquat University of Medical and Health Sciences Jamshoro, form January 2020 to June 2020.
 Material & Method: Inclusion criteria for this study were patients aged 18-60 years visiting the outpatient department with primary/recurrent fistula having symptoms. Among these individuals having anal fistula due to secondary causes like IBD, tuberculosis or any malignancy were not included in the study. VAAFT was performed by experience general surgeon and post-operative follow up was done till 1 years.
 Results: A total of 68 patients with fistula in ano were selected for video assisted anal fistula treatment (VAAFT) in our setup. It included 67.6% (n=46) males and 32.3% (n=22) females who agreed for the procedure. The mean age of patients were found to be 43+13 years. Post-operatively complete healing was observed in 75% (n=51) patients and 14.7% patients had persistent fistula after the procedure. 
 Conclusion: VAAFT is a minimally invasive surgical intervention implied to treat primary and recurrent anal fistulas, having lesser rates of recurrence and few post-operative complications. It should be implied over large scales for treatment of primary and recurrent anal fistula as it carries the lowest rate of anal incontinence.

Fisurectomy and anoplasty with botulinum toxin injection in patients with chronic anal posterior fissure with hypertonia: a long-term evaluation

Chronic anal fissure’s (CAF) etiopathogenesis remain unclear. CAF of the posterior commissure (CAPF) are often characterized by internal anal sphincter (IAS) hypertonia. The treatment of this disease aimed to reduce IAS hypertonia. Due to the high rate of anal incontinence after LIS, the employment of sphincter preserving surgical techniques associated to pharmacological sphincterotomy appears more sensible. The aim of our study is to evaluate the long-term results of fissurectomy and anoplasty with V–Y cutaneous flap advancement associated to 30 UI of botulinum toxin injection for CAPF with IAS hypertonia. We enrolled 45 patients undergone to fissurectomy and anoplasty with V–Y cutaneous flap advancement and 30 UI botulinum toxin injection. All patients were followed up for at least 5 years after the surgical procedure, with evaluation of anal continence, recurrence rate and MRP (Maximum resting pressure), MSP (Maximum restricting pressure), USWA (Ultrasound wave activity). All patients healed within 40 days after surgery. We observed 3 “de novo” post-operative anal incontinence cases, temporary and minor; the pre-operative ones have only temporary worsened after surgery. We reported 3 cases of recurrences, within 2 years from surgery, all healed after conservative medical therapy. At 5 year follow-up post-operative manometric findings were similar to those of healthy subjects. At 5 years after the surgical procedure, we achieved good results, and these evidences show that surgical section of the IAS is not at all necessary for the healing process of the CAPF.

A systematic review of non-invasive modalities used to identify women with anal incontinence symptoms after childbirth.

Anal incontinence following childbirth is prevalent and has a significant impact upon quality of life (QoL). Currently, there is no standard assessment for women after childbirth to identify these symptoms. This systematic review aimed to identify non-invasive modalities used to identify women with anal incontinence following childbirth and assess response and reporting rates of anal incontinence for these modalities. Ovid Medline, Allied and Complementary Medicine Database (AMED), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Collaboration, EMBASE and Web of Science databases were searched for studies using non-invasive modalities published from January 1966 to May 2018 to identify women with anal incontinence following childbirth. Study data including type of modality, response rates and reported prevalence of anal incontinence were extracted and critically appraised. One hundred and nine studies were included from 1602 screened articles. Three types of non-invasive modalities were identified: validated questionnaires/symptom scales (n = 36 studies using 15 different instruments), non-validated questionnaires (n = 50 studies) and patient interviews (n = 23 studies). Mean response rates were 92% up to 6weeks after childbirth. Non-personalised assessment modalities (validated and non-validated questionnaires) were associated with reporting of higher rates of anal incontinence compared with patient interview at all periods of follow-up after childbirth, which was statistically significant between 6weeks and 1year after childbirth (p < 0.05). This systematic review confirms that questionnaires can be used effectively after childbirth to identify women with anal incontinence. Given the methodological limitations associated with non-validated questionnaires, assessing all women following childbirth for pelvic-floor symptomatology, including anal incontinence, using validated questionnaires should be considered.

Operative vaginal delivery in case of persistent occiput posterior position after manual rotation failure: a 6-month follow-up on pelvic floor function.

To compare the short- and long-term perineal consequences (at 6 months postpartum) and short-term neonatal consequences of instrumental rotation (IR) to those induced by assisted delivery (AD) in the occiput posterior (OP) position, in case of manual rotation failure. A prospective observational cohort study; tertiary referral hospital including all women presenting with persistent OP position who delivered vaginally after manual rotation failure with attempted IR or AD in OP position from September 2015 to October 2016. Maternal and neonatal outcomes of all attempted IR deliveries were compared with OP operative vaginal deliveries. Main outcomes measured were pelvic floor function at 6 months postpartum including Wexner score for anal incontinence and ICIQ-FLUTS for urinary symptoms. Perineal morbidity comprised severe perineal tears, corresponding to third and fourth degree lacerations. Fetal morbidity parameters comprised low neonatal Apgar scores, acidaemia, major and minor fetal injuries and neonatal intensive care unit admissions. Among 5265 women, 495 presented with persistent OP positions (9.4%) and 111 delivered after manual rotation failure followed by AD delivery: 58 in the IR group and 53 in the AD in OP group. The incidence of anal sphincter injuries was significantly reduced after IR attempt (1.7% vs. 24.5%; p < 0.001) without increasing neonatal morbidity. At 6 months postpartum, AD in OP position was associated with higher rate of anal incontinence (30% vs. 5.5%, p = 0.001) and with more urinary symptoms, dyspareunia and perineal pain. OP operative deliveries are associated with significant perineal morbidity and pelvic floor dysfunction at 6 months postpartum.

Anal incontinence and fecal urgency following vaginal delivery with episiotomy among primiparous patients

ObjectiveTo investigate anal incontinence following mediolateral or lateral episiotomy during a first vaginal delivery. MethodsThe present prospective follow-up study enrolled primiparous patients who underwent vaginal delivery including mediolateral or lateral episiotomy between April 1, 2010 and March 31, 2012. Participants completed interviews before delivery, and were given anal-incontinence questionnaires to be returned for analysis at 3 months and 6 months postpartum. Anal incontinence was defined as a St Mark’s incontinence score above four and individual anal-incontinence components were analyzed separately; results were compared between the two episiotomy techniques. ResultsQuestionnaires were returned by 300 and 366 patients who underwent mediolateral and lateral episiotomies, respectively; baseline characteristics were similar. Anal incontinence at 3 months and 6 months was recorded among 21 (7.0%) and 9 (3.0%) patients who underwent mediolateral and 27 (7.4%) and 20 (5.5%) who underwent lateral episiotomy, respectively. The study was underpowered to confirm equivalence between the groups; however, no statistically significant differences were observed in the rates of anal incontinence, flatus, solid or liquid incontinence, and de novo incontinence. Fecal urgency (P=0.017) and de novo fecal urgency (P=0.008) were more prevalent among patients who underwent lateral episiotomies at 6 months. ConclusionAnal incontinence was comparable between primiparous patients who underwent mediolateral or lateral episiotomy. The association between lateral episiotomy and fecal urgency merits further scientific interest.

Use of endoanal ultrasound for reducing the risk of complications related to anal sphincter injury after vaginal birth.

Use of endoanal ultrasound for reducing the risk of complications related to anal sphincter injury after vaginal birth.

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

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

Symptoms after obstetric sphincter injuries have little effect on quality of life

To compare the prevalence of anal incontinence and dyspareunia in women with or without obstetric sphincter injury after standardizing the suture technique. Retrospective case-control study. Regional hospital, Sweden. 305 women with an obstetric sphincter injury and 297 women with spontaneous vaginal delivery. In order to standardize and improve the repairing skills of sphincter injuries, collaboration between obstetricians and colorectal surgeons was begun in 2000. Inner and external sphincters were repaired in two layers with continuous monofilament polidioxane sutures. The participating women received a questionnaire with validated questions on anal incontinence, dyspareunia and quality of life. The follow-up time was 15 months to 8 years. Anal incontinence, dyspareunia and quality of life. Of the sphincter group, 72% returned the questionnaire, as did 67% in the control group. Significantly more women in the sphincter group suffered from incontinence of flatus and loose stool compared to controls (p < 0.05). There was no significant difference of incontinence of solid stool, soiling, or fecal urgency between the groups. The quality of life questions showed no significant difference between the groups. In the sphincter group, there was significantly more superficial coital pain compared to controls (p= 0.02). Significantly more women with complete sphincter injury reported anal incontinence than women with a partial sphincter injury. In spite of increased rate of anal incontinence and dyspareunia after anal sphincter rupture, there was no statistically significant reduction in the women's quality of life.

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

To report on a 3-year follow-up of women who underwent overlapping repair of a complete third-degree or fourth-degree obstetric tear. Primiparous women sustaining a complete third-degree or a fourth-degree tear of the perineum were randomized to a primary sphincter repair using either an end-to-end or an overlapping surgical technique. At 1, 2, and 3 years, questionnaires on rates of flatal and fecal incontinence were mailed to participants. At 1 year, women who underwent an end-to-end repair reported lower rates of flatal and fecal incontinence than women who had an overlapping repair. For flatal incontinence the rates were 31% compared with 56% (95% confidence interval for the rate difference 6-43%, P=.012). For fecal incontinence, the rates were 7% compared with 16% (95% confidence interval for the rate difference -4% to 21%, P=.17). The difference between the two methods of surgical repair had largely disappeared by the end of year 2. At 1-year follow-up, end-to-end repair of complete third-degree or fourth-degree obstetric anal sphincter tears is associated with significantly lower rates of anal incontinence when compared with overlapping repair. There is no long-term benefit associated with either technique over the other. ISRCTN Register, http://isrctn.org, ISRCTNO 4149919. I.

Anal and urinary incontinence 4 years after a vaginal delivery

Our purpose was to establish the incidence of anal and urinary incontinence 4 years following vaginal delivery in women with and without obstetric anal sphincter injuries (OASIS). This was a prospective study of 241 having their first vaginal delivery who had independent verification and repair of OASIS by trained obstetricians. All obstetricians performing OASIS repairs had undergone structured hands-on training and were then directly supervised while repairing OASIS until they were deemed competent to repair independently. Patients were followed up for 4 years with validated bowel and urinary questionnaires. In order to minimise nonresponders, contact details were verified and obtained from their general practitioners, the local primary care trust and electoral roll. Two hundred and fifty-four women were invited, and 241 (95 %) participated. Fifty-nine (25 %) women sustained OASIS. One hundred and forty-nine were contactable 4 years later, and 86 (58 %) agreed to participate in the study at 4 years. No woman had faecal incontinence, and there was no difference in rates of flatus incontinence prior to delivery up to 4 years postpartum, regardless of whether OASIS occurred or not. Urinary incontinence was more than four times more common after vaginal birth, and this was not affected by whether OASIS occurred and resulted in a significant deterioration in quality of life. The previously reported higher rates of anal incontinence following OASIS can be minimised up to 4 years after delivery if repaired by trained doctors. There is a significant increase in urinary incontinence following vaginal delivery, and the mechanism for this is not linked to anal sphincter disruption.

Manometric Evaluation of Internal Anal Sphincter after Fissurectomy and Anoplasty for Chronic Anal Fissure: A Prospective Study

Chronic anal fissure (CAF) is a common painful clinical disease and its pathogenesis remains poorly understood. After failure of pharmacological therapy, that is the first-line treatment, surgical sphincterotomy remains the treatment of choice although it is followed by a high rate of anal incontinence resulting from the sphincter damage; therefore, the research of a sphincter-saving surgical option has become an important goal. The aim of this study was to evaluate the manometric modifications and the incidence of anal incontinence after fissurectomy and anoplasty with advancement skin flap in patients affected by CAF with hypertonia of the internal anal sphincter (IAS). Fifteen patients affected by CAF with hypertonia of IAS, unresponsive to medical therapy, were enrolled. All subjects underwent fissurectomy and anoplasty with advancement skin flap. Anorectal manometry was performed preoperatively and after 6 and 12 months from surgery. Maximum resting pressure (MRP), maximum squeeze pressure (MSP), ultraslow wave activity (USWA), fissure healing, anal continence, and postoperative complications were recorded. All patients healed within 30 days from surgery. No intra- or postoperative complications were recorded except for a case of partial donor site break. No significant modifications of MSP were detected. Six months after surgery, MRP was higher with respect to healthy subjects but significantly reduced in comparison to baseline levels. At 12 months, it was higher have versus 6-month values but significantly lower versus preoperative values. USWA was significantly represented in patients with CAF versus healthy subject. Both at 6 and 12 months, they decreased significantly with respect to preoperative values without significant differences versus healthy subjects. Both at 6 and 12 months, anal continence did not differ with respect to preoperative time. The fissurectomy with anoplasty resulted in a high healing rate without surgical sequelae or anal incontinence. Also, it was able to reduce IAS pressure in the same manner as surgical sphincterotomy or forceful dilatation.

Botulinum toxin injection versus lateral internal sphincterotomy for the treatment of chronic anal fissure: randomized prospective controlled trial

Lateral internal sphincterotomy has been the gold standard treatment for chronic anal fissure, but it still carries the risk of permanent damage of the anal sphincter, which has led to the implementation of alternative treatment like botulinum toxin injection. The aim of this randomized prospective controlled trial was to compare the efficacy and morbidity of botulinum toxin injection and lateral internal sphincterotomy in the treatment of chronic anal fissure. Fifty consecutive adults with chronic anal fissure were randomly treated with either lateral internal sphincterotomy or botulinum toxin (BT) injection with 50 U BT into the internal sphincter. The complications, healing and recurrence rate, and incontinence score were assessed 2, 3, 6, 12 months after the procedure. Inspection at the 2-month visit revealed complete healing of the fissure in 11 (44 %) of the patients in the BT group and 22 (88 %) of the patients in the lateral internal sphincterotomy (LIS) group (p = 0.001). At the 3-month visit, there was no significant difference between the two groups in healing. The overall recurrence rate after 6 months in the BT group was higher than in the LIS group (p < 0.05). In the 3-month follow-up, the LIS group had a higher rate of anal incontinence compared to the BT group (p < 0.05). The final percentage of incontinence was 4 % in the LIS group (p > 0.05). The treatment of chronic anal fissure must be individualized depending on the different clinical profiles of patients. Botulinum toxin injection has a higher recurrence rate than LIS, and LIS provides rapid and permanent recovery. However, LIS carries a higher risk of anal incontinence in patients.

Botulinum Toxin Injection Versus Lateral Internal Sphincterotomy in the Treatment of Chronic Anal Fissure: A Randomized Controlled Trial

Although lateral internal sphincterotomy has been the gold standard of treatment for chronic anal fissure, the main concern remains its effects on anal continence. Intrasphincteric injection of botulinum toxin seems to be a reliable option providing temporary alleviation of sphincter spasm and allowing the fissure to heal. The aim of the present prospective controlled randomized study was to compare the outcome of lateral internal sphincterotomy and botulinum toxin injection treatments in patients with uncomplicated chronic anal fissure. Eighty consecutive patients with uncomplicated chronic anal fissure who had failed conservative treatment were randomized to receive either intrasphincteric injection of botulinum toxin (BT) or lateral internal sphincterotomy (LIS). Postoperative pain relief, healing of fissure, continence scores, and fissure relapse during 18weeks of follow-up were the outcomes assessed. There was a statistically significantly higher healing in the LIS group than the BT group (p=0.0086 and 95%CI=7.38-45.69%). In addition, LIS was associated with a high rate of anal incontinence as compared to BT (p=0.0338 and 95%CI=-1.64-27.53%). The recurrence rate in the BT group was significantly higher statistically than that in the LIS group (p=0.0111 and 95%CI=6.68-46.13%). Surgical internal sphincterotomy has a higher healing rate and a lower recurrence rate than intrasphincteric injection of botulinum toxin in the treatment of uncomplicated chronic anal fissure. Injection of botulinum toxin, however, is a simple noninvasive technique that avoids the greater risk of incontinence. It could be used as the first therapeutic approach in patients without clinical risk factors of recurrence.

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

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

Prevalence and risk factors of anorectal dysfunction in women with urinary incontinence

To evaluate the prevalence and risk factors of anorectal dysfunction among women with urinary incontinence. This cross-sectional study was conducted among women attending the urogynecology clinic. Women with symptoms of urinary incontinence were requested to complete a structured questionnaire. Four hundred and thirteen women participated in the study and 43.8% had at least one anorectal symptom. The prevalence rates of anal incontinence, constipation, and difficult defecation were 8.0, 38.0, and 25.7%, respectively. The risk factors associated with anorectal dysfunction were age and number of parity. Anorectal dysfunction was prevalent among women with urinary incontinence; age and number of parity were the risk factors. All women with symptoms of urinary incontinence should be evaluated about anorectal symptoms.

MANAGEMENT OF FISTULA IN ANO

Aim: The aim of this study was to compare the efficacy and morbidity of two surgical procedures, firm cutting seton andloose seton / fistulotomy in the management of suprasphincteric and high trans-sphincteric fistula in ano. Setting: Jinnah Hospital / AllamaIqbal Medical college, Lahore. Period: June 1999 to January 2008. Methods: This is a prospective, randomized study of 50 consecutivepatients (25 in each group) suffering from suprasphincteric and high trans-sphincteric fistula in ano. Patients were randomly allocated oneof the two methods of treatment. In firm cutting seton, seton was repeatedly tightened with the interval of 15 days till the thread came outwhereas loose seton / fistulotomy was a two staged surgical procedure. Follow up was made for 12months to record the fistula recurrence,anal incontinence, duration of complete wound healing and number of hospitalizations. Comparison was made using standard statisticalmethods. Chi-square and Fisher's Exact test was applied for comparison. Results: There was no significant statistical difference betweenthe groups in age, sex and type of fistula. Patient treated with loose seton / fistulotomy required more than one hospitalization, more offwork and more expenditures as compared to firm cutting seton method. The rate of anal incontinence was more in patients treated withloose seton / fistulotomy. Recurrence rate was almost the same in both groups. Conclusion: Both techniques are equally effective ineradication of fistula but the rate of postoperative anal incontinence and duration of complete healing of the wound is more in patients treatedwith loose seton / fistulotomy.

Anorectal, bladder, and sexual function in females following colorectal surgery for carcinoma

The aim of this study was to establish the incidence of potential postoperative anorectal, bladder, and sexual dysfunction in women following excision of rectal cancer with total mesorectal excision (TME). All women who underwent a transabdominal rectal resection with TME for cancer between 2000 and 2003 were included. Women with a colonic resection for cancer during the same time period served as the control group. Exclusion criteria were strict. Standardized questionnaires were sent to all patients. Twenty-six patients fulfilled the inclusion criteria and were evaluated. Fifteen patients had TME and 11 patients had colonic resection. The median Wexner score showed a higher rate of anal incontinence in the rectal group. The difference was due to a higher rate of severe incontinence in the rectal group. The King's Health Questionnaire showed normal urinary function in both groups. The Female Sexual Function Index showed worse sexual function in the rectal group, reaching statistical significance in the categories 'arousal' and 'lubrication'. After rectal excision, the women showed impairment of their anorectal and sexual function. Urinary function was normal. This is in contrast to the incidence of urinary dysfunction in men observed by others. Our study indicates that women seem to have less functional problems when compared to literature data on dysfunction in male following rectal surgery for cancer.

Internal Sphincterotomy Versus Rotation Flap to Treat Chronic Anal Fissures

The motivation to develop alternatives to lateral internal sphincterotomy for the treatment of anal fissure rests mainly on the risk of anal incontinence following the procedure. In recent years, pharmacological treatment with smooth muscle relaxants has been the most widely studied. Surgical alternatives have taken the form of flap procedures that purport to heal fissures by resurfacing and revascularization. In this issue of the Asian Journal of Surgery, Singh et al reports a case series using a rotational flap procedure.1 The series, though small, describes treatment of chronic anal fissure without impairment of continence. The paper does not make it clear how successful the rotation flap was in healing anal fissure. In two of their 14 patients, the anal fissure failed to heal. A randomized comparison with internal sphincterotomy would have been useful in determining technical superiority. A randomized controlled trial comparing an advancement flap with internal sphincterotomy in the treatment of anal fissure showed no statistical difference in healing rate between the two.2 There was a trend towards non-healing in the flap procedure group due to flap failure. Interestingly, no incontinence was reported in either group. There has been a tendency to over-emphasize the risk of incontinence following internal sphincterotomy. A 2% rate of anal incontinence has been reported with tailored sphincterotomy where there was careful attention to the amount of sphincter divided.3 A prospective trial of lateral internal sphincterotomy reported by Hyman showed similarly low rates of incontinence, with even fewer patients reporting an impairment in quality of life.4 Despite the grim prognostication of advocates of medical and flap alternatives, lateral internal sphincterotomy is some way from becoming a relic of surgery for anal fissure. Flap procedures have a role in the treatment of anal fissure in cases where incontinence is a genuine risk following sphincterotomy. Examples of this would include female patients with short anal canals and the elderly or multiparous who already have a degree of impaired anal continence.