Risk Of Fecal Incontinence Research Articles

Faecal incontinence after vaginal delivery

Advances in the ease and accuracy with which the anal sphincter mechanism can be investigated by ultra-sonography (the anatomy) and by studies of pudendal-nerve latency (the nerve supply to the external sphincter) have revealed that about a third of women sustain damage to the anal muscles and their nerve supply during normal childbirth. In many cases such damage occurs without obvious tearing of the perineum, 1 Sultan AH Kamm MA Hudson CM Thomas JM Bartram CI Anal sphincter rupture during vaginal delivery. N EngI J Med. 1993; 329: 1905-1911 Crossref PubMed Scopus (1395) Google Scholar yet of the 3–4% of women in the general population who present later in life with faecal incontinence, 2 Rieger NA Wattchow DA The effect of vaginal delivery on anal function: a review. Aust NZ J Surg. 1999; 69: 172-177 Crossref PubMed Scopus (28) Google Scholar most have sphincter tears on ultrasonography. 3 Deen KI Kumar D Williams A Olliff J Keighley MRB The prevalence of anal sphincter defects in feacal incontinence: a prospective endosonic study. Gut. 1993; 34: 685-688 Crossref PubMed Scopus (145) Google Scholar Effect of second vaginal delivery on anorectal physiology and faecal continence: a prospective studyPrimiparous women with persistent symptoms of altered faecal continence experience deterioration after a second vaginal delivery. Women with transient faecal incontinence or occult anal-sphincter injury after their first vaginal delivery are at high risk of faecal incontinence after a second vaginal delivery. The risk of mechanical anal sphincter injury is greatest after the first delivery. Full-Text PDF

Effect of second vaginal delivery on anorectal physiology and faecal continence: a prospective study

Because obstetric injury to the anal sphincters may be occult, and because the mechanism of injury differs between first and subsequent deliveries, we prospectively assessed the effects of first and second vaginal deliveries on anal physiology and continence. We undertook a prospective observational study of 59 previously nulliparous women through two successive vaginal deliveries by means of a bowel-function questionnaire, and an anorectal-physiology assessment, both antepartum and 6-12 weeks post partum. 13 (22%) women reported altered faecal continence after their first vaginal delivery: eight had persistent symptoms during their second pregnancy, of whom seven deteriorated after the second delivery; five regained continence before their second pregnancy, but two became incontinent again after the second delivery. Five women developed incontinence for the first time after their second vaginal delivery, of whom three had occult primiparous sphincter injury. 20 (34%) women, seven of whom had no symptoms, had anal-sphincter injury as a result of their first delivery, but only two new injuries occurred after the second vaginal delivery (p=0.013). Although pudendal neuropathy was no more common after the second than after the first vaginal delivery (15 vs 19%, p=0.8), pudendal-nerve latency was longer after the second delivery (p=0.02). Primiparous women with persistent symptoms of altered faecal continence experience deterioration after a second vaginal delivery. Women with transient faecal incontinence or occult anal-sphincter injury after their first vaginal delivery are at high risk of faecal incontinence after a second vaginal delivery. The risk of mechanical anal sphincter injury is greatest after the first delivery.

Continent appendicostomy in the bowel management of fecally incontinent children

Background: Fecal incontinence is common in children who have anorectal malformations, Hirschsprung's Disease, and spina bifida and can negatively impact their emotional and social development. Enemas have been used as an artificial way to keep children clean and to improve their quality of life. This method is unpleasant for many children, particularly when they reach adolescence. Malone in 1990 described an alternative method in which the appendix is used as a conduit to administer an antegrade enema. Methods: The authors describe their experience with this new procedure, modified by them, and used in 20 patients. In the original procedure, the base of the appendix is divided, inverted, and reimplanted into the cecum with an antireflux technique. The authors simplify this by plicating the cecum around the appendix to create a one-way valve mechanism but leaving the appendix in its original position. The authors also mobilize the cecum and exteriorize the appendix at the umbilicus to create an inconspicuous stoma. If the native appendix is absent a neoappendix was created from a flap of cecum. Results: Nineteen of 20 patients (95%) are now completely clean 24 hours a day. Stricture of the stoma occurred in two patients and required revision. Leakage at the appendicostomy site occurred in three patients, and two required a tighter plication. Conclusions: The technique is used to change the route of enema administration, and is only used in patients for whom bowel management with rectal enemas has been proven successful. The appendix must be preserved whenever possible in patients at risk for fecal incontinence.

Effects of age on anal function in normal women.

To study effects of age on anal function in healthy women. A study of 75 women with no known anorectal disease, aged 20 to 83 (mean 50) years, mean parity 2 (range 0-4). Perineal position at rest (PR), descent during straining (PS), maximum resting pressure (MRP) maximum squeeze pressure (MSP) of the anal sphincters, and pudendal nerve terminal motor latency (PNTML) were measured. Data were analysed using the multiple regression technique including age and parity in the model. Increasing age was significantly associated with a weakening of anal function. PR and PS were both lowered (P < 0.0001 and P = 0.0001). Anal sphincter pressures were reduced (MRP: P = 0.004, MSP: P = 0.015), and age was associated with an increased mean PNTML (P < 0.0001). All associations seemed to be linear. Parity was associated with a lowering of both PR and PS but not with the other parameters. Age accounted for 13-44% of the total variability seen in the tests of pelvic floor function. Age leads to a consistent reduction in anal function and this is likely to increase the risk of faecal incontinence in old age. From the current data we suggest that in normal women with an uncomplicated obstetric history increasing age is associated with significant changes in anal function whereas long-term effects of vaginal deliveries play a minor role. Moreover our results suggest gradual changes throughout adult life, rather than large changes occurring after menopause.

Age and Anorectal Sensibility in Normal Women

Background: Our aim was to study associations between age and anorectal sensibility in healthy women. Methods: Seventy-five women, with a mean age of 50 (range, 20–83) years, and mean parity of 2 (range, 0–4). were studied. Anal mucosa electrosensitivity (AME) was measured 1 and 2 cm from the anal verge. Rectal sensibility was also measured (minimum perceived volume (MPV), desire to defaecate (DD), and urgency (U)). Associations between anorectal sensibility and age were corrected for parity by using multiple regression analysis. Results: Threshold values of AME increased with age (P = 0.03 (1 cm) and P = 0,01 (2 cm)). Rectal sensibility threshold values were also positively associated with age (MPV, P = 0.003; DD, P = 0.04; and U, P = 0.06). Changes in AME were greater after menopause, whereas associations between rectal sensibility and age seemed linear. Conclusion: Impairment of the anorectal sensibility appears to be part of the normal ageing process, thus increasing the risk of faecal incontinence in old women.

Pudendal Nerve Damage Increases the Risk of Fecal Incontinence in Women With Anal Sphincter Rupture After Childbirth

Tetzschner, Tine; Sorensen, Michael; Rasmussen, Ole O.; Lose, Gunnar; Christiansen, JohnAuthor Information

Cutting seton without preliminary internal sphincterotomy in management of complex high fistula-in-ano

The traditional treatment of a complex high fistula-in-ano by internal sphincterotomy and insertion of a cutting seton carries a risk of fecal incontinence. We have assessed the functional impact of treating patients with a complex fistula-in-ano by a cutting seton fistulotomy technique that preserves the internal sphincter. The operative steps consisted of initial eradication of sepsis, identification of the internal and external openings of the fistula tract, excision of the fistula tract with anal canal mucosa, and insertion of a cutting silk seton around both the internal and external sphincters. In this way open drainage of the intersphincteric space was avoided, and integrity of the internal sphincter was maintained. Functional outcome following treatment with this technique, with regard to fistula eradication and effect on fecal continence was assessed in 27 patients (15 males) who were treated during a six-year period. Twenty-three patients (85 percent) had a history of previous fistula surgery. The fistula was cured in 26 patients (96 percent) with no reports of altered continence at the time of discharge from outpatient review. Recurrence developed in one patient (4 percent) in whom hidradenitis suppurativa was subsequently diagnosed. All four patients with Crohn's disease had their fistulas eradicated; three (75 percent) have subsequently undergone proctectomy for severe perianal and rectal Crohn's involvement. Long-term follow-up revealed three patients (19 percent, all rectovaginal fistulas) who experienced a deterioration in continence after discharge. Although this procedure may not be appropriate for rectovaginal fistulas, the data suggest that cutting setons are effective in treating complex fistula-in-ano, including those that have failed to respond to other forms of surgery. Avoidance of preliminary internal sphincterotomy may prevent deterioration in continence.