Risk Factors For Incontinence Research Articles

Incontinence urinaire après prostatectomie ouverte ou laparoscopique pour cancer prostatique localisé. Une revue de la littérature

Evaluate urinary continence after radical prostatectomy. Recent series about urinary continence were studied. In seven articles analyzed, continence fluctuated between 63.6 and 91.9%. Evaluation benchmarks were depending on study. Unlike self-questionnaires, objective criteria (pad test) should be more reliable. Carcinologic prognostic factors were not implicated directly. The most frequently preoperative risk factors of incontinence were: age, BMI. Peroperative parameters, attesting of surgical difficulties could have a functional impact. Bladder neck preservation could affect the recovery velocity but not functional results. Length of catheterization and lack of urinary rehabilitation could be influent. The mean of continence evaluation after radical prostatectomy was different for each study. Comparability was difficult because operative technique, group's features and mean of functional evaluation were different from study to study. Several risk factors were found but without consensus. It would be necessary to separate carcinologic and functional risk factors.

Influence of maternal weight on the new onset of stress urinary incontinence in pregnant women

The aim of the study was to investigate the incidence and severity of stress urinary incontinence (SUI) in primigravid women at term and its association with maternal body weight. This was an observational study of 458 primigravid women who came to give birth at Donostia Hospital during 2007. Urinary symptoms were investigated (2002 ICS definitions), and a physical examination including height, weight, pelvic floor muscle strength, and fetal presentation was performed. We calculated the incontinence severity index (ISI) and the women answered the International Consultation on Incontinence short form questionnaire. SUI affected 139 (30.3%) primigravid women. The ISI distribution was 40.3% slight, 54.7% moderate, 4.3% severe, and 0.7% very severe. Pregnant women at term with body weight >or=75 kg appear to have more than doubled the risk of presenting SUI. The incidence of SUI is high in pregnancy. Increased maternal body weight at term is an independent risk factor for incontinence.

Urinary incontinence among Taiwanese women: an outpatient study of prevalence, comorbidity, risk factors, and quality of life

The objective of this study was to evaluate comorbidity and risk factors associated with female urinary incontinence and to assess quality of life for women with different types of urinary incontinence. Subjects included 551 consecutive females who attended the outpatient clinic from 9 March to 8 July 2006 and did not have a chief complaint of incontinence. A four-item incontinence questionnaire and a Chinese version of the Incontinence-Quality of Life (I-QOL) questionnaire were completed in the waiting room. Patient characteristics and medical conditions were summarized from outpatient electronic databases. A total of 371 females were included for statistical analysis. Among them, 114 patients (30.7%) did not indicate any urinary incontinence, while 257 (69.3%) patients indicated symptoms of urge incontinence, stress incontinence, or mixed incontinence. Comorbidities significantly associated with incontinence included osteoarthritis (P = 0.001), peptic ulcer disease (P = 0.031), obesity (P < 0.001), and cardiac disease (P < 0.001). After multiple logistic regression analysis, obesity (OR 3.38, 95% CI 1.94-6.98) and postmenstrual status (OR 2.17, 95% CI 1.35-3.50) were found to be risk factors of incontinence (P < 0.001). Mixed incontinence patients exhibited the least satisfaction in quality of life, while no significant differences were observed between patients with urge incontinence and stress incontinence. In conclusion, the incidence of urinary incontinence may be greater in the outpatient population than previously thought. Osteoarthritis, peptic ulcer disease, and cardiac disease are more common in women with urinary incontinence, obesity and postmenopausal status appear predictive of incontinence, and women with mixed incontinence exhibit the least satisfying quality of life.

Effect of Mode of Delivery on the Incidence of Urinary Incontinence in Primiparous Women

To estimate the effect of mode of delivery on the incidence of urinary incontinence in primiparous women. A population-based survey was mailed to all Oregon women who delivered a liveborn neonate in a 1-year period. Data were collected on urinary incontinence, childbirth experience, and other risk factors for incontinence at 3-6 months postpartum. Univariable analyses were conducted using t tests and Wilcoxon rank-sum tests for continuous variables and chi tests for categorical variables. Logistic regression analyses were used to estimate odds ratios and 95% confidence intervals for demographic and clinical risk factors. A total of 15,787 women completed the survey, for a response rate of 39%. Of these women, 5,599 were primiparous, completed the survey in the desired timeframe, submitted information on their urinary continence, and did not have incontinence before pregnancy. A total of 955 (17.1%) reported leakage of urine. Women who had vaginal deliveries were more likely to have urinary incontinence than women who had cesarean deliveries (odds ratio 4.96 [95% confidence interval 3.82-6.44], P<.001). This risk increased with assisted delivery and perineal laceration. No statistical difference in the incidence of urinary incontinence was found among women who had elective cesarean deliveries (6.1%), women who had cesarean deliveries after laboring (5.7%), and women who had cesarean deliveries after laboring and pushing (6.4%). Urinary incontinence is common in the immediate postpartum period after a woman's first pregnancy. Although vaginal delivery increases the risk of urinary incontinence, labor and pushing alone without vaginal delivery do not appear to increase this risk significantly. II.

A systematic review of overweight and obesity as risk factors and targets for clinical intervention for urinary incontinence in women

To review the epidemiological literature of urinary incontinence with respect to overweight and obesity as a risk factor, and how the findings eventually fulfill general criteria for being a causal factor for the condition. Likewise to review all interventional studies assessing the effect of weight reduction on incontinence. Systematic searches until June 2008 for publications of community based prevalence studies with bivariate or multivariate analyses of the association between urinary incontinence in women and overweigh/obesity. In addition an attempt was made to identity and assess all relevant longitudinal studies, prospective case series, and trials, whatever design. There is evidence 3 and some evidence 2 level data to support that in addition to BMI, waist-hip ratio and thus abdominal obesity may be an independent risk factor for incontinence in women. Only a few interventional studies have been carried out to assess the effect of weight reduction on incontinence. Five studies report effect on incontinence after surgical weight reduction procedures, and one study after a weight reduction program, thus giving some level 2 documentation. There are three RCTs which all show reducing incontinence by weight loss (level of evidence 1). Epidemiological studies document overweight and obesity as an important risk factor for urinary incontinence. There is now valid documentation for weight reduction as a treatment for urinary incontinence in women.

Does the impact of subsequent incontinence risk factors depend on continence status during the first pregnancy or the postpartum period 12 years before? A cohort study in 232 primiparous women

Assess the impact of subsequent urinary incontinence risk factors in women with different urinary incontinence history. In a cohort study 232 women answered validated questions about urinary incontinence after the first delivery and 12 years later. Women who were continent during the first pregnancy or postpartum period (group 1) or who became incontinent during these periods (group 2) were identified. Urinary incontinence symptoms 12 years after the first delivery were reported by 32.6% (44/135) in group 1 and 66.0% (64/97) in group 2. Overweight and to a minor extent pelvic organ prolapse symptoms or heavy lifting at work was associated with higher relative risk of urinary incontinence in group 1 compared with group 2. Other risk factors such as age, breastfeeding 6 months or longer after both the first and second deliveries, bowel movements or urinary infections were not associated differentially with urinary incontinence in the 2 groups. Subsequent risk factors had a more significant impact in women without initial urinary incontinence.

Invited Commentary: The Contribution of the BACH Survey to the Epidemiology of Urinary Incontinence

Despite a substantial number of epidemiologic studies of urinary incontinence over the past two decades, relatively little is known about urinary incontinence in non-White women or in men. By enrolling White, Black, and Hispanic men and women, the Boston Area Community Health (BACH) Survey has added to our limited knowledge of incontinence in these groups. In general, the results from BACH, reported in the current issue of the American Journal of Epidemiology (Tennstedt et al., Am J Epidemiol 2008;167:390-399), confirm prior findings in women while extending our knowledge of the prevalence of and risk factors for incontinence in men. Interpretation of the BACH Survey results must be tempered by the low enrollment rate (less than 25% of eligible community members). The associations between cardiovascular disease and incontinence reported for some gender/race-ethnicity subgroups should be considered exploratory.

Urinary Incontinence After Radical Prostatectomy

Incontinence after radical prostatectomy for early stage prostate cancer can significantly affect quality of life. Identification of risk factors preoperatively would enable clinicians to counsel men and their partners about the risk of incontinence following surgery. We conducted a population-based study to identify subjective and objective preoperative factors, other than PSA and Gleason score, that may predict urinary incontinence following radical prostatectomy. Men booked for radical prostatectomy at 2 sites in Alberta were enrolled prospectively. Assessment was completed 2 weeks prior to surgery and included the International Prostate Symptom Score (IPSS) with a single quality-of-life (QOL) question, 24-hour pad test, and bladder diary. These parameters were repeated at 3 and 12 months postoperatively. A model predicting incontinence was developed using stepwise multivariable logistic regression analysis. Incontinence was defined as more than 8 g of urine loss on 24-hour pad test. A total of 245 patients from 2 centers were enrolled; 228 (93%) completed data collection up to 12 months postsurgery. At the baseline preoperative assessment, 4% (10/228) of subjects had > or = 8 g of urine loss on 24-hour pad test, although these and all other subjects described complete continence. At 3 months postop, 43% had > or = 8 g on 24-hour pad testing (our definition of incontinence) (median 31 g, range 8.3-1654 g, SD 219.12); at 12 months, 15% had more than 8 g of urine loss on pad test (median 21.0 g, range 8.1-3380 g, SD 578.0). For all subjects, mean IPSS and the single QOL scores at baseline (7.4 and 1.5) did not change significantly at 3 months (7.2 and 2.5), but both were lower than or equal to baseline at 12 months (5.4 and 1.5). The IPSS was predictive of incontinence at 3 months, but not at 12 months. Bladder diary did not correlate with IPSS. Risk factors affecting continence at 12 months were preoperative urine loss > or = 8 g, previous transurethral resection of prostate (TURP), and age greater than 65 years. Our results support previous research on risk factors for incontinence after radical prostatectomy and add to the current data by having presurgery (baseline) measures. Interestingly, a small percentage of men (4%) who reported complete continence were incontinent preoperatively, based on our definition of > or = 8 g weight gain on 24-hour pad test. Identified preoperative risk factors affecting continence were increasing age, baseline incontinence, and previous TURP. Mean IPSS was lower at 12 months than at baseline, suggesting that even mildly symptomatic men will improve after surgery. Men reported that regular contact with the continence research nurse provided a much-appreciated source of informed support as they recovered.

Urinary Incontinence During Pregnancy

To investigate incidence and prevalence of urinary incontinence during pregnancy and associated risk factors. The data collection was conducted as part of the Norwegian Mother and Child Cohort Study at the Norwegian Institute of Public Health. We present questionnaire data about urinary incontinence obtained from 43,279 women (response rate 45%) by week 30. We report data on any incontinence, in addition to type, frequency, and amount of incontinence. Potential risk factors were investigated by logistic regression analyses. The prevalence of incontinence increased from 26% before pregnancy to 58% in week 30. The corresponding figures for nulliparous women were 15% and 48%, and for parous women 35% and 67%. The cumulative incidence was 46%. Stress urinary incontinence was the most common type of incontinence in week 30 of pregnancy, experienced by 31% of nulliparous and 42% of parous women. The majority of pregnant women had leakage less than once per week and droplets only, both before and during pregnancy. Parity was a strong and significant risk factor for incontinence in adjusted analyses both before pregnancy (odds ratio [OR] 2.5, 95% confidence interval [CI] 2.4-2.7 for primiparous and OR 3.3, 95% CI 3.1-3.5 for multiparous women) and during pregnancy (ORs 2.0, 95% CI 1.9-2.1 and 2.1, 95% CI 2.0-2.2, respectively). Age and body mass index were weaker, but still statistically significant, risk factors. The prevalence of urinary incontinence increases substantially during pregnancy. Incontinence both before and during pregnancy seems to be associated with parity, age, and body mass index. II.

The Prevalence of Urinary Incontinence Among Community Dwelling Men: Results From the National Health and Nutrition Examination Survey

To measure the prevalence of urinary incontinence in community dwelling men in the United States, we analyzed data from respondents to the National Health and Nutrition Examination Survey. From 1999 to 2000 the National Health and Nutrition Examination Survey asked a national sample of community dwelling men, "In the past 12 months, have you had difficulty controlling your bladder, including leaking small amounts of urine when you cough or sneeze?" Questionnaire results were recorded and analyzed with respect to demographic data, and compared to the National Health and Nutrition Examination Survey data in women. The overall prevalence of urinary incontinence in men was 17%. Prevalence increased with age from 11% in men 60 to 64 years old to 31% in men 85 years old or older. Of the men reporting any incontinence 42% reported daily incontinence and 24% reported it weekly. Black men had the highest prevalence of male incontinence (21%) and black women had the lowest prevalence of female incontinence (20%). While the prevalence of incontinence in black women was virtually the same as that in black men, the prevalence of incontinence in white and Mexican-American women was at least 2.5 times that of men of the same ethnicity. The National Health and Nutrition Examination Survey draws a nationally representative sample of subjects from the community and, thus, provides prevalence data for urinary incontinence for all men in the United States. Ethnicity appears to be a contributing risk factor for incontinence, although racial patterns clearly differ between men and women.

Epidemiology of Stress, Urgency, and Mixed Incontinence: Where Do the Boundaries Cross?

Urinary incontinence is a common condition; however, lack of conformity in the definitions used in epidemiologic studies of incontinence makes results difficult to interpret. Current estimates suggest that about one third of cases of urinary incontinence are of the mixed type. Parity is a key risk factor for incontinence, as is increasing age. It also appears that the proportion of women with urgency and mixed incontinence, rather than stress incontinence, is greater with increasing age. Evidence suggests that mixed and urgency incontinence have a comparable impact on quality of life that is greater than the effect of stress incontinence. Further consideration needs to be given to the way that mixed incontinence is defined to allow a more accurate and complete picture to be established of the importance of mixed incontinence relative to other forms of incontinence.

Systematic review: the treatment of anal fissure

Anal fissure is one of the most common anorectal conditions encountered in clinical practice. Most patients experience anal pain with defecation and minor bright red rectal bleeding, allowing a focused history to direct the evaluation. A systematic medical literature search of NIH, Pubmed, and MEDLINE using the search terms anal fissure, sphincterotomy, anal surgery and anal fissure medical therapy. English language was not a restriction. Cited references were used to find additional studies. No single treatment is the best choice for all patients. Because pharmacological therapy is not associated with permanent alterations in continence, a trial of either a topical sphincter relaxant or botulin toxin injection, along with adequate fluid and fibre intake, is a reasonable option. However, because pharmacological therapy has lower healing and higher relapse rates, surgery can be offered in the first instance to patients without incontinence risk factors who have severe, unrelenting pain and are willing to accept a small risk of incontinence, for the highest likelihood of prompt healing and the lowest risk of recurrence. Both non-operative and operative approaches currently exist for the management of anal fissure. Improved non-surgical therapies may continue to lessen the role of sphincter-dividing surgery in future.

Urinary incontinence after radical prostatectomy: incidence by definition, risk factors and temporal trend in a large series with a long‐term follow‐up

To investigate the incidence of urinary incontinence and its development over time, to compare the effects of alternative definitions on the incontinence rate and to explore risk factors for incontinence after radical retropubic prostatectomy (RRP) for clinically localized prostate cancer. Urinary continence was assessed using a questionnaire administered by a third party in 1144 consecutive patients after undergoing RRP at our department from January 1986 to December 2001. Overall, 985 men (86%) were suitable for evaluation (mean age 64.5 years, mean follow-up 95.5 months). We compared the effects of three definitions on the actuarial rate of continence: (1) no or occasional pad use; (2) 0 or 1 pads used daily, but for occasional dribbling only; (3) 0-1 pads daily. The time to recovery of continence was defined as the date on which the patient met the continence definitions. The impact of incontinence on health-related quality of life (HRQoL) was also evaluated. Univariate and multivariate analyses were used to identify predictors of incontinence, using data gathered prospectively. At the last follow-up at 24 months after RRP, 83%, 92.3% and 93.4% of men achieved continence according to definitions 1, 2 and 3, respectively. The difference in time to recovering continence was significant for definition 1 compared to the others (P < 0.001). Most men using 1 pad/day complained of occasional dribbling only (89.3%), considered themselves continent (98%) and their HRQoL was not as seriously affected as those requiring > or = 2 pads/day. Men continent (by definition 3) at 2 years had an actuarial probability of preserving continence of 72.2% at the last follow-up. On multivariate analysis the age at surgery (P = 0.009), anastomotic stricture and follow-up interval (both P < 0.001) were independent prognostic factors. Bilateral neurovascular bundle resection was another independent predictive factor (P = 0.03) in the subset of the last 560 men with available data on surgical technique. The reduction in the incidence of incontinence over time was as high as 86%. Continence improves progressively until 2 years from RRP but some patients can become incontinent later. The criterion of pad use discriminates well between men with a limited reduction in their QoL (no or one pad used) and those with a markedly affected QoL (> or =2 pads/day). It could be clinically valid to consider users of 1 pad/day as continent. Age, bilateral neurovascular bundle resection and anastomotic stricture are significant risk factors for incontinence. There was a marked trend for the incidence of incontinence and anastomotic stricture to decrease with time.

Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity

Although obesity and physical activity have been argued to predict back pain, these factors are also related to incontinence and breathing difficulties. Breathing and continence mechanisms may interfere with the physiology of spinal control, and may provide a link to back pain. The aim of this study was to establish the association between back pain and disorders of continence and respiration in women. We conducted a cross-sectional analysis of self-report, postal survey data from the Australian Longitudinal Study on Women's Health. We used multinomial logistic regression to model four levels of back pain in relation to both the traditional risk factors of body mass index and activity level, and the potential risk factors of incontinence, breathing difficulties, and allergy. A total of 38,050 women were included from three age-cohorts. When incontinence and breathing difficulties were considered, obesity and physical activity were not consistently associated with back pain. In contrast, odds ratios (OR) for often having back pain were higher for women often having incontinence compared to women without incontinence (OR were 2.5, 2.3 and 2.3 for young, mid-age and older women, respectively). Similarly, mid-aged and older women had higher odds of having back pain often when they experienced breathing difficulties often compared to women with no breathing problems (OR of 2.0 and 1.9, respectively). Unlike obesity and physical activity, disorders of continence and respiration were strongly related to frequent back pain. This relationship may be explained by physiological limitations of co-ordination of postural, respiratory and continence functions of trunk muscles.

Incontinence in the elderly

Geriatric incontinence is a prevalent problem, morbid, costly and has effects that are devastating, causing psychological dysfunction, which often leads to isolation and early admission to a residential care facility. The reported prevalence of urinary incontinence (UI) in the elderly varied widely between 10% and 70% in those over 65 years of age. There is evidence that less than half of the patients with UI consult their healthcare provider. Incontinence is associated with significant anxiety and depression which has negative effect on self perception. Continence depends on multiple factors – mental state, mobility, manual dexterity, health status and motivation – as well as urinary function. The aetiology and risk factors of incontinence in older people are little different from those in younger age groups but the elderly are more prone to physiological, pharmacological and psychological factors that may affect their incontinence status. Assessment of elderly patients with UI should follow a holistic approach; it must include transfer ability, mobility, balance, arm strength and body flexibility, manual dexterity, eyesight and toileting ability. Simple conservative measures such as general lifestyle advice are all that is needed in many cases. Primary care team including continence advisors play important role in treating these patients. Pelvic-floor exercise, bladder retraining and biofeedback are useful first-line management, but they require intact cognitive function and motivation. Due to the side effects, older people should be observed carefully when given new medications, and polypharmacy should be avoided at all cost. Age in itself is not a barrier to surgical treatment, especially if performed under local anaesthesia. Environmental measures are an essential part of the treatment package. Preventive strategies should be used, when possible, to reduce the burden of incontinence on elderly sufferers and enhance their quality of life.

Surgical versus chemical (botulinum toxin) sphincterotomy for chronic anal fissure: Long-term results of a prospective randomized clinical and manometric study

Background The aim of this prospective randomized trial was to compare the effectiveness and morbidity of surgical versus chemical sphincterotomy in the treatment of chronic anal fissure after a 3-year follow-up. Methods Eighty patients with chronic anal fissure were treated by whether open lateral internal sphincterotomy (group 1) or chemical sphincterotomy with 25 U botulinum toxin injected into the internal sphincter (group 2). Clinical and manometric results were analyzed. Results Overall healing was 92.5% in the open sphincterotomy group and 45% in the toxin botulinum group ( P <.001). There is a group of patients with clinical (duration of disease >12 months and presence of a sentinel pile before treatment) and manometric factors (persistently elevated mean resting pressure, % of time presence of slow waves, and number of patients or the time presence ultra slow waves after treatment) associated with a higher recurrence of anal fissure. The final percentage of incontinence was 5% in the open sphincterotomy group and 0% in the botulinum toxin group ( P > .05). Conclusion We recommend surgical sphincterotomy as the first therapeutic approach in patients with clinical and manometric factors of recurrence. We prefer the use of botulinum toxin in patients older than 50 years or with risk factors for incontinence, despite the higher rate of recurrence, since it avoids the greater risk of incontinence in the surgical group.

Surgical (close lateral internal sphincterotomy) versus chemical (botulinum toxin) sphincterotomy as treatment of chronic anal fissure

The aim of this prospective randomized trial was to compare the effectiveness and morbidity of surgical vs chemical sphincterotomy in the treatment of chronic anal fissure after a 3-year follow-up period. Eighty patients with chronic anal fissure were treated either with close lateral internal sphincterotomy (group 1) or with chemical sphincterotomy with 25 U botulinum toxin injected into the internal sphincter (group 2). Overall healing was 90% in the close sphincterotomy group and 45% in the toxin botulinum group (p < 0.001). There was a group of patients with clinical factors (duration of disease over 12 months and presence of a sentinel pile before treatment) associated with a higher recurrence of anal fissure. Final percentage of incontinence was 5% in the close sphincterotomy group and 0% in the botulinum toxin group (p > 0.05). All incontinent patients were aged more than 50 years. We recommend surgical sphincterotomy as the first therapeutic approach in patients with clinical factors of recurrence. However, we recommend the use of botulinum toxin in patients older than 50 years or with associated risk factors of incontinence, despite the higher rate of recurrence, since it avoids the greater risk of incontinence seen with surgery.

Risk factors for the development of fecal and urinary incontinence in Wisconsin nursing home residents

Purpose: To determine factors associated with the development of urinary and fecal incontinence in nursing homes. Design and methods: Residents of Wisconsin skilled nursing facilities reported in the Wisconsin annual nursing home survey continent to both urine and stool in 1992 were re-assessed 1 year later for the development of urinary and/or fecal incontinence. Independent variables were elements of the HCFA minimum data set found to be significantly associated with incontinence in cross-sectional surveys of Wisconsin nursing home residents. Results: Dementia and advancing age were consistently associated with the development of incontinence, but the strongest associations were impairment of activities of daily living and the use of patient restraints. Implication: Adjusting for the major reasons to apply patient restraint: dementia, blindness, arthritis and stroke, along with other risk factors for incontinence, the use of patient restraints is the most significant cause for the development of incontinence in nursing homes.

Urologic Complications of Diabetes

Diabetes and urologic diseases are very common health problems that markedly increase in prevalence and incidence with advancing age (1–3). Diabetes is associated with an earlier onset and increased severity of urologic diseases, resulting in costly and debilitating urologic complications. Urologic complications, including bladder dysfunction, sexual and erectile dysfunction, as well as urinary tract infections (UTIs), have a profound effect on the quality of life of men and women with diabetes. This review presents a comprehensive overview of the current understanding of clinical and basic research on urologic complications of diabetes and recommendations for future directions for research and clinical care. Over 50% of men and women with diabetes have bladder dysfunction (4,5). Current understanding of bladder dysfunction reflects a progressive condition encompassing a broad spectrum of lower urinary tract symptoms including urinary urgency, frequency, nocturia, and incontinence. Previously, the dysfunction has been classically described as diminished bladder sensation, poor contractility, and increased postvoid residual urine, termed bladder cystopathy (6). However, bladder cystopathy most likely represents end-stage bladder failure with symptoms of infrequent voiding, difficulty initiating voiding, and postvoid fullness and is relatively uncommon. A number of clinical studies in men and women with diabetes have reported bladder instability or hypersensitivity as the most frequent finding, ranging from 39–61% of subjects (5,7). Diminished bladder contractility or sensation has been found less often (5), and an acontractile bladder appears to be quite uncommon. ### Bladder dysfunction in women In women, urinary incontinence is estimated to affect nearly 50% of middle aged and older women, leading to significant distress, limitations in daily functioning, and poorer quality of life (8,9). Diabetes has been identified as an important independent risk factor for incontinence in several large observational studies, including the Nurses’ Health Study, and is associated with 30–100% increased risk (9 …

Long-term results of botulinum toxin for the treatment of chronic anal fissure: prospective clinical and manometric study

The aim of this prospective trial was to analyse the effectiveness and morbidity of chemical sphincterotomy in the treatment of chronic anal fissure after a 3-year follow-up. One hundred consecutive patients with chronic anal fissures were treated by chemical sphincterotomy with 25 U botulinum toxin injected into the internal sphincter. Clinical and manometric results were recorded. No major complications were found; initial incontinence at the 2-month review (6%) spontaneously reversed at 6 months. There was a tendency of progressive recurrence over time, with an overall healing after 3 years of 47%. We found a group of patients with clinical (symptoms longer than 12 months and presence of a sentinel pile before treatment) and manometric factors (persistently elevated mean resting pressure, percentage of time with slow waves, and number of patients or percentage of time with ultra slow waves after treatment) associated with a higher recurrence of anal fissures. Since it avoids the greater risk of incontinence associated with surgical sphincterotomy, we recommend the use of botulinum toxin as the first therapeutic approach for patients with chronic anal fissure and risk factors for incontinence; despite the higher rate of recurrence associated with this treatment. In patients with factors related to recurrence, re-injection with higher doses of botulinum toxin or complementary medical-surgical treatment should be considered.