Sphincter In Women Research Articles

Long-term results of artificial urinary sphincter in women: A retrospective monocentric study

BackgroundStress urinary incontinence (SUI) is a public health issue, with major impact on quality of life. An efficient treatment for intrinsic sphincter deficiency (ISD) is the artificial urinary sphincter (AUS). ObjectivesAnalyzing patient survival in terms of revision-free survival, removal-free survival and global survival without reintervention long-term results concerning continence status and complications. DesignWomen with severe ISD and negative Bonney test who were treated with AUS first implantation between 1987 and 2022 were included. ResultsIn our study, 478 patients were treated by AUS first implantation with a mean age of 59.7. The median follow-up time was 13.2years. The median revision-free survival was 19.5years with survival rates at 10, 20 and 30years were 86%, 47% and 32% respectively. Removal-free survival rates at 10, 20 and 30years were 84%, 80% and 60% respectively. Median reintervention-free survival was 17.5years. Survival was negatively affected by neurological etiology of the ISD, history of previous incontinence treatment and intraoperative complications with more early removals in the latter group. The absence of previous incontinence surgery was a protecting factor. Continence status was assessed at 10, 20 and 30years follow-up with a fully continence rate of respectively 83%, 68% and 61%. Intraoperative complication rate was 17.7%, explantation rate was 14% and the revision rate was 23%. ConclusionWomen treated with AUS have an excellent revision-free, removal-free and global survival rate. AUS is a very efficient treatment for women with ISD in terms of continence results with an acceptable intraoperative and long-term complication rate of which patients should be well informed before choosing this treatment for their SUI.

Eighteen years of experience in laparoscopic implantation of artificial urinary sphincter in women with intrinsic sphincter deficiency

Introduction and objectives: Artificial urinary sphincter (AUS) is a treatment option for women with stress urinary incontinence (SUI) after failure of previous surgery or as a primary procedure in severe intrinsic sphincter deficiency (ISD). The aim of the study was to assess the long-term efficacy and risk factors for surgical revision and definitive explantation of AUS laparoscopic implantation in female patients.Methods: A retrospective review of all women submitted to AUS implantation between April 2005 and March 2023 was conducted. The AUS was implanted via transperitoneal laparoscopic approach, by two experienced surgeons. The primary endpoint was postoperative continence. Continence was defined as no leakage and no pad usage or leakage and/or pad usage with no impact on social life and failure as leakage and/or pad usage impacting social life. As secondary outcomes, clinical predictive factors for AUS revision and definitive explantation were evaluated.Results: In the last 18 years, females with a mean age of 68±12 years-old were submitted to laparoscopic implantation of AUS. Early overall complication rate was 16%, but only one case was Clavien-Dindo ≥3. After a median follow-up of 67 months, 22.2% of the patients needed a device revision, the majority due to mechanical device dysfunction. AUS definitive explantation was performed in 16%, mainly due to urethral/vaginal erosion (9.9%) and infection (6.2%). Patients with age ≥70 years and follow-up ≥10 years significantly predisposed for device revision. At the time of the last follow-up, 72% of the patients were keeping the urinary continency.Conclusions: Laparoscopic AUS implantation in females is an effective treatment for SUI due to ISD. Meanwhile, adequate patient selection, multidisciplinary evaluation and careful expectation management are essential to achieving good results, concerning their significant complication rate.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula.

Place of Duloxetine in Concervative Treatment Women and Men with Stress Urinary Incontinence

History of introduction of duloxetine in medical practice, mechanism of action and using of duloxetine in concervative treatment women and men with stress urinary incontinence are shown. Modern structure of external urethral sphincter in women and men was shown with increasing of sphincter tone under duloxetine influence.
 Duloxetine recommended by International Continent Society for initial treatment women with stress urinary incontinence but this drug gives only improvement of urine continence and quality of life with side effects. Duloxetine with connection with pelvic floor muscle training gives better results than using separately duloxetine and pelvic floor muscle training. Nausuea is the most frequency side symptom after using duloxetine. Results of own investigations were shown and indications for using duloxetine in women with stress urinary incontinence were summed up. The most positive results were obtained after combination of duloxetine with pelvic floor muscle training and electrostimulation of urethral sphincter. Duloxetine for treatment men with stress urinary incontinence after radical prostatectomy is only clinical tested. Estimation of efficacy of duloxetine in treatment men with stress urinary incontinence after open prostatectomy due to benign prostatic hyperplasia is needed.

Outcomes of laparoscopic artificial urinary sphincter in women with stress urinary incontinence: mid-term evaluation.

Although artificial urinary sphincter (AUS) has become an established treatment for moderate to severe stress urinary incontinence (SUI), implantation can be challenging. This study aimed to review the outcomes of laparoscopic AUS (LAUS) implantation and revision in women presenting with SUI. We reviewed the files of female patients presenting with moderate to severe SUI treated with LAUS implantation from October 2007 to July 2017. Surgeries were performed by one surgeon experienced in open AUS implantation and starting LAUS implantation. The primary endpoint was postoperative urinary continence, which was divided into three categories: complete continence, improved continence, and unchanged incontinence. The secondary outcomes were complications, explantation-free and revision-free time. A total of 49 women (mean age 64years, range 40-80) had LAUS implantation. Among the 42 patients (85.7%) with an AUS in place at the last follow-up, 25 (59.5%) were fully continent, 16 (38.1%) had improved continence, and 1 (2.4%) had unchanged incontinence. At the lastfollow-up, 29 (59.2%) patients had their initial AUS and 13 (26.5%) had at least one reintervention. There were 9 (18.4%) intraoperative complications and 25 (51%) postoperative complications, of which 9 (18.4%) were Clavien⩾3. After a median follow-up of 4years, 9 (18.4%) explantations and 11 (22.5%) revisions occurred. The average period without explantation or revision was 3.7 and 3.1years, respectively. Our study shows that the laparoscopic approach for AUS implantation is an efficient treatment option for women with moderate to severe SUI.

Maternal birth trauma: how imaging can (and should) change clinical practice.

Maternal birth trauma: how imaging can (and should) change clinical practice.

Sphincter muscle activity before and after delivery: Does it depend on the type of birth?

There are ongoing discussions whether cesarean section is the safest mode of childbirth to prevent pelvic floor disorders. Pelvic floor electromyography (EMG) allows the analysis of external anal sphincter (EAS) function during voluntary contractions. The primary objective of this study was the evaluation of EMG amplitude of external anal sphincter in women who had vaginal delivery, compared to women who had cesarean section. The secondary objective was to evaluate the anal incontinence score changes before and after delivery between the groups, and to look for any relationship between the clinical and EMG findings. Multichannel surface EMG was detected during maximal contractions in three sessions: (i) during pregnancy, (ii) 6 weeks after delivery and (iii) 1 year after delivery. Women were divided into two groups: cesarean section and vaginal delivery. External anal sphincter EMG amplitude decreases 6 weeks after vaginal deliveries from 10.1 to 8.6 μV with effect size of 0.4, but returns to baseline after 1 year. No differences were observed between groups in all other variables. No differences were observed after 1 year in EMG activity between the two groups; however, a slight decrease of sphincter muscle amplitude was noted 6 weeks after vaginal delivery. The delivery mode does not have effect on the EAS amplitude 1 year after delivery. Incontinence score slightly increased in both groups after delivery, with no significant differences between the two groups. No association was observed between the increase of incontinence score and the decrease of EMG signal amplitude.

369 - Outcomes of laparoscopic artificial urinary sphincter in women with stress urinary incontinence

369 - Outcomes of laparoscopic artificial urinary sphincter in women with stress urinary incontinence

Effects of delivery mode and age on motor unit properties of the external anal sphincter in women.

This study aimed to assess the individual and interactive effects of delivery mode and age on the function of the external anal sphincter (EAS) by analyzing the motor unit properties with intramuscular electromyography (EMG). Results are expected to improve the understanding of delivery-related occult obstetric EAS injuries and its development over the aging process and further support early clinical detection and intervention. A total of 49 postpartum women were recruited into four test groups according to their age and delivery mode: young vaginal delivery (Y-VD), elderly vaginal delivery (E-VD), young cesarean section (Y-CS), and elderly cesarean section (E-CS) groups. Anorectal ultrasonography, manometry, and intramuscular EMG were employed for comprehensive evaluation of EAS function. No significant difference in anorectal ultrasonography and most manometry measurements was associated with delivery age or mode. Intramuscular EMG, however, revealed a statistically significant difference in the characteristics of motor unit potentials (MUPs), including duration, turns, phases, and multiphase wave ratio between four subject groups. No significant interaction effect between age and delivery mode was found. Delivery mode and age have a significant effect on the neuromuscular function of the EAS, suggesting a potential protectiveness of cesarean section against impairment to the EAS. Our results do not provide significant evidence regarding the interaction effect of delivery mode and age; further investigations are needed to confirm this conclusion.

V05 - Robot-assisted implantation of artificial urinary sphincter in women: A standardized surgical technique

V05 - Robot-assisted implantation of artificial urinary sphincter in women: A standardized surgical technique

Outcomes of open artificial urinary sphincter in women with stress urinary incontinence: long-term follow up

Background:The aim of this study was to report the outcomes of artificial urinary sphincter (AUS) in women with stress urinary incontinence (SUI) resulting from intrinsic sphincter deficiency after a follow up of 10 years.Methods:The charts of female patients with moderate-to-severe SUI who underwent open AUS implantation between November 1994 and April 2007 were reviewed retrospectively. All patients were operated on by a single experienced surgeon through an open retropubic approach with systematic bladder incision. Primary endpoint was postoperative continence categorized as complete continence (no pads used), improved incontinence, or unchanged incontinence.Results:A total of 63 women (mean age: 58 years, range: 17–82) underwent open AUS implantation. There were seven (11.1%) intraoperative complications. At the last follow up, 26 (41.3%) initial AUSs remained in situ and 21 (33.3%) patients had at least one revision or reimplantation. Of these 47 patients (74.6%), 35 (74.5%) were fully continent, 3 (6.4%) had improved incontinence, and 9 (19.1%) had unchanged incontinence. A total of 20 patients (31.7%) experienced postoperative complications, but only 2 (3.2%) were Clavien ⩾3. After a median follow up of 14 ± 6 years, 20 (31.7%) explantations and 29 (46%) revisions occurred. The average time without explantation or revision was 11.6 and 9 years, respectively.Conclusions:In our experience, AUS is a good option for women with moderate to severe SUI, with good long-term outcomes.

Establishing the normal ranges of female and male anal canal and rectal wall vascularity with color Doppler anorectal ultrasonography

Study objectivesTo evaluate blood supply in the anal canal, rectal wall and mesorectal fat of men and women, using color Doppler endorectal sonography to establish normal ranges for vascular parameters. MethodsA prospective cross-sectional study conducted at a tertiary-care hospital recruited asymptomatic volunteers (≤50 years). Vascularity percentage and index were calculated for defined regions. ResultsVascularity percentage and index were significantly higher in the puborectalis, mid-level external and upper internal anal sphincter compared to the low anal canal; these parameters were higher in men than in women at upper and middle levels of the inner anal canal structures. At mid-level, vascularity was greater in the external compared to the internal anal sphincter in both sexes; however, at the upper level it was greater in the puborectalis compared to the internal anal sphincter in women. Vascularity was greater in the rectal wall compared to the mesorectal fat, with no difference between middle and lower levels. ConclusionsBlood supply is highest at upper levels of the anal canal; however, inner structures are better irrigated in men. Moreover, the rectal wall is better irrigated than the mesorectal fat. Establishing normal ranges may permit future comparisons of the studied structures in disease states as well as the hormonal and age related changes.

V80 - Robot-assisted implantation of artificial urinary sphincter in women: Standardization of the surgical technique

V80 - Robot-assisted implantation of artificial urinary sphincter in women: Standardization of the surgical technique

AB305. SPR-32 Aging effects on the central motor control of the external anal sphincter in women

ObjectiveAccumulated clinical evidence has shown that aging is associated with deficits in the central nerve system (CNS) that leads to disruption in descending excitation. Whether this is true in pelvic floor muscles remains unclear. This study aimed to study whether there is evidence of an aging-associated decreasing descending excitation to the motoneuron pool of the external anal sphincter (EAS) in women.MethodsSurface electromyography (EMG) signals of the EAS were acquired from 14 female subjects (38.6±16.6 years, range: 20–73 years, no anorectal disorders) during maximum squeeze using a high-density rectal probe. Motor unit (MU) action potentials were separated using our K-means clustering and convolution kernel compensation algorithm, with the firing rate of each MU obtained. The mean MU firing rate, a key marker to assess the motor control of the CNS, was calculated for all decomposed MUs for each subject. Linear regression analysis was performed to study the impact of aging on the mean MU firing rate.ResultsThe mean MU firing rate was 7.4±2.1 Hz. Linear regression showed a decreasing, though not significant, trend with advancing age (P=0.10), suggesting a possible deficit in the CNS of aged women in driving the lower motoneurons to activate the EAS. Our ongoing recruitment of more aged women will help us consolidate this observation, to offer valuable insights into the mechanism of aging-associated anorectal disorders.ConclusionsThis study represents the first effort to use advanced high-density surface EMG analysis to noninvasively evaluate aging effects on the central motor control of the EAS in women.Funding Source(s)NIH DK082644 and the University of Houston

OC09.05: Evaluation of the anal sphincter in women with obstetric anal sphincter injuries: comparison between transperineal and endoanal ultrasound techniques

OC09.05: Evaluation of the anal sphincter in women with obstetric anal sphincter injuries: comparison between transperineal and endoanal ultrasound techniques

Mode of delivery after obstetric anal sphincter injury

ObjectiveTo assess the effect of vaginal delivery and caesarean section on faecal symptoms and structure and function of anal sphincter in women who sustained obstetric anal sphincter injuries (OASIS) in their previous pregnancy and were advised about the mode of delivery based on faecal incontinence symptoms, anal manometry and endoanal ultrasound. Study designIt is a descriptive study on a cohort of women who had OASIS from 2006 to 2013. They were assessed after OASIS and during subsequent pregnancy with a questionnaire, endoanal ultrasound and anal manometry. Vaginal delivery was recommended to asymptomatic women with normal investigations. Elective caesarean section was recommended to women with faecal symptoms, anal sphincter defects of more than 30° or low resting or incremental anal pressures. All women were reassessed after subsequent delivery. ResultsFifty women who had pregnancies after OASIS, were seen after OASIS, during subsequent pregnancy and after the second delivery. 15 women had faecal symptoms after OASIS. The external, internal and combined anal sphincter defects were seen in 13, 11 and 9 women respectively. Low resting and incremental pressure were seen in 15 and 11 women respectively. Caesarean section was done in 22 women and 28 women delivered vaginally. Worsening of faecal symptoms and reduction in anal pressures were not observed in planned vaginal delivery or elective caesarean section groups. Faecal symptoms were worse with reduced anal pressures in three women from the planned caesarean section group. One of the women had a vaginal delivery and two women had emergency caesarean section at 7cm and 10cm dilatation. There were no new sphincter defects or recurrent OASIS in any of the women in the study group. ConclusionDecision about the mode of delivery of pregnancy after OASIS based on symptoms, anal manometry and endoanal ultrasound helps in preserving the anal sphincter function and avoiding unnecessary caesarean sections. Further follow-up of these patients is essential to evaluate the long-term effects of this decision.

Robotic-assisted laparoscopic implantation of artificial urinary sphincter in women with intrinsic sphincter deficiency incontinence: initial results.

To investigate the feasibility, safety, and functional results of robotic-assisted artificial urinary sphincter (R-AUS) laparoscopic implantation in women with stress urinary incontinence due to intrinsic sphincter deficiency. Six women underwent an R-AUS implantation between 2012 and 2013. The mean age was 65 ± 9.6 years. Five patients had previous surgery for incontinence. The mean duration of follow-up was 14.3 months. A transperitoneal approach with a lateral positioning of the robotic arms was performed. The cuff implantation, positioning of the reservoir, and the pump were carried out similarly to the laparoscopic technique. Operative time, intraoperative occurrence of injuries of the bladder or vagina, postoperative complications, and continence (pad per day) were assessed. The R-AUS implantation was feasible in all cases without intraoperative injury and 1 grade 1 postoperative complication. Mean operative time, postoperative bladder catheterization, and hospitalization time were 210 ± 32 minutes, 7 days, and 6 days, respectively. At the end of the follow-up, 83% of cases were fully continent. R-AUS implantation in incontinent women with intrinsic sphincter deficiency was feasible and safe with good functional results. More data are needed before concluding to the superiority of this new technique compared with open or laparoscopic approaches.

Changes in urethral sphincter size following rehabilitation in older women with stress urinary incontinence.

The purpose of this study was to evaluate the effects of a pelvic floor muscle (PFM) rehabilitation program on the striated urethral sphincter in women over 60 years with stress urinary incontinence (SUI). We hypothesized that the PFM rehabilitation program would also exercise the striated urethral sphincter and that this would be demonstrated by hypertrophy of the sphincter on magnetic resonance imaging (MRI). Women with at least weekly episodes of SUI were recruited. Participants were evaluated before and after a 12-week group PFM rehabilitation intervention with T2-weighted fast-spin-echo MRI sequences recorded in the axial plane at rest to assess urethral sphincter size. Data on SUI symptoms and their bother were also collected. No control group was included. Seventeen women participated in the study. The striated urethral sphincter increased significantly in thickness (21%, p < 0.001), cross-sectional area (20%, p = 0.003), and volume (12%, p = 0.003) following the intervention. The reported number of incontinence episodes and their bother also decreased significantly. This study appears to demonstrate that PFM training for SUI also trains the striated urethral sphincter and that improvement in incontinence signs and symptoms is associated with sphincter hypertrophy in older women with SUI. These findings support previous ultrasound (US) data showing an increase in urethral cross-sectional area following PFM training and extend the previous findings by more specifically assessing the area of hypertrophy and by demonstrating that older women present the same changes as younger women when assessed using MRI data.

Pelvic floor muscle training in women with stress urinary incontinence causes hypertrophy of the urethral sphincters and reduces bladder neck mobility during coughing

The purpose of this study was to determine the effect of a 12-week pelvic floor muscle (PFM) training program on urethral morphology and mobility in women with stress urinary incontinence (SUI). Forty women with SUI were randomly assigned to one of two groups: the treatment group received 12 weekly physiotherapy sessions during which they learned how to properly contract their pelvic floor muscles (PFMs) and a home exercise program was prescribed, reviewed, and progressed; the control group received no treatment. Before and after the 12-week study period, ultrasound imaging was used to evaluate bladder neck position and mobility during coughing and Valsalva maneuver in supine and in standing, as well as urethral morphology. Secondary outcome measures included a 3-day bladder diary, 30-min pad test, the Incontinence Impact Questionnaire (IIQ-7) and the Urogenital Distress Inventory (UDI-6). The women in the treatment group demonstrated reduced bladder neck mobility during coughing and increased cross-sectional area of their urethra after as compared to before the training. These changes were not evident in the control group. No differences in the resting position of the bladder neck or in bladder neck excursion during Valsalva maneuver were noted in either group. Concomitantly the women in the treatment group demonstrated significant improvements in the 3-day bladder diary and IIQ-7 after the PFM training and improved significantly more than the control group. Physiotherapist-supervised PFM training reduces bladder neck motion during coughing, and results in hypertrophy of the urethral sphincter in women who present with SUI.

Fatigue rate of the external anal sphincter

Studies of skeletal muscle show that fatigue rate corresponds to the proportion of fast-twitch and slow-twitch fibres that are present in the muscle. Limited work has been done on the fatigue rate of the external anal sphincter. We have prospectively studied fatigability of the external anal sphincter in women with faecal incontinence and women with normal bowel control. Anorectal manometry was measured by a station-pull technique using a water-filled microballoon. Fatigue rate was calculated from anal pressure measurements taken every 0.1 s over a 20-s squeeze. Women with faecal incontinence (n=88, median -12 cmH(2) O/min) were less susceptible to fatigue than women with normal bowel control (n=36, median -43 cmH(2) O/min) (P<0.01). The external anal sphincter was less susceptible to fatigue with increasing age (P<0.01, r=0.499). In women with normal bowel control and in women with faecal incontinence fatigue rate was negatively correlated with maximum squeeze pressure (P<0.01, r=-0.287; P<0.01, r=-0.579). The external anal sphincter was less susceptible to fatigue with increasing age. Women with faecal incontinence have a weaker but more fatigue-resistant external anal sphincter. This might correspond to a higher proportion of slow-twitch muscle fibres. Histological studies are needed to examine this hypothesis.