Sphincter Integrity Research Articles

Use of 2D and multislice transperineal ultrasonography to describe the degree of perineal laceration following vaginal delivery

Background: Perineal tear is the most common complication after vaginal delivery. Pill-rolling test is a widely used clinical evaluation method to determine the degree of perineal tear. However, the evaluation results of anal sphincter complex (ASC) differ between clinical examination and 2D/multislice transperineal ultrasonography (TPUS). This study aims to describe measurement variation between these modalities.Methods: This cross-sectional study was conducted at Cipto Mangunkusumo Hospital from November 2015 to May 2016. Subjects were primiparous women after vaginal delivery. Clinical examination using pill-rolling test was performed to determine the degree of perineal laceration. Suture was conducted accordingly. The subjects were subjected to 2D/multislice TPUS 72 hours after delivery to evaluate the integrity of internal and external anal sphincters. Data were collected and analyzed to determine compatibility between these examinations.Results: Among 70 prospective primiparous women, five were excluded due to unavailability to undergo 2D/multislice TPUS 72 hours after delivery. The mean duration to perform 2D/multislice TPUS was 4.5 minutes, and pain was tolerable during the examination. The compatibility values of clinical examination with 2D and multislice TPUS were 0.98 and 0.93, respectively, with Cohen’s kappa of 0.92 (95% CI 0.81–1.00) and 0.79 (95% CI 0.58–0.99), respectively.Conclusion: Clinical examination is compatible with 2D/multislice TPUS for determining the degree of perineal tear after vaginal delivery.

High-resolution Anorectal Manometry Measures Are More Accurate Than Conventional Measures in Detecting Anal Hypocontractility in Women With Fecal Incontinence

Anorectal manometry is a common test of anal tone and contractility. However, existing measures are often criticized for their poor ability to detect functional differences between individualswith presumably normal sphincter function and individuals with fecal incontinence. We investigated whether new measures, derived from high-resolution anal manometry (HR-ARM), more accurately identify incontinent women with abnormal sphincter function than measures from conventional anal manometry (C-ARM). We performed a prospective HR-ARM study of 85 healthy female volunteers (median age 41 years; range 18-68 years) and 403 women with fecal incontinence (median age 55; range 18-91 years) from June 2013 through December 2015. We compared the diagnostic accuracy of conventional measurements of contractility (C-ARM squeeze increment) and tone (C-ARM resting pressure) (the reference standards), with HR-ARM measures (HR-ARM squeeze increment, HR-ARM contractile integral, HR-ARM resting average, HR-ARM rest integral). We also investigated associations between symptom severity and structural sphincter integrity. We identified anal hypocontractility in 129 women with fecal incontinence using the C-ARM squeeze increment (32% sensitivity; likelihood ratio, 6.4), in 189 women using the HR-ARM squeeze increment (47% sensitivity; likelihood ratio, 9.4), and in 220 women using the HR-ARM contractile integral (55% sensitivity; likelihood ratio, 11.0). In contrast, HR-ARM measures of anal tone did not particularly outperform conventional measures (31% sensitivity for HR-ARM resting average vs 28% for C-ARM resting pressure). Ninety-eight of the 206 patients with fecal incontinence who were classified as having normal anal function, based on C-ARM measures, were reclassified as having abnormal function based on HR-ARM measures. In a prospective study of healthy women and women with fecal incontinence, we demonstrated that the newly developed HR-ARM contractile integral increased the sensitivity of detection ofanal hypocontractility, from 32% to 55%, compared with conventional measurements of squeeze.

Effect of subsequent vaginal delivery on bowel symptoms and anorectal function in women who sustained a previous obstetric anal sphincter injury

Introduction and hypothesisOur primary objective was to prospectively evaluate anorectal symptoms, anal manometry and endoanal ultrasound (EAUS) in women who followed the recommended mode of subsequent delivery following index obstetric anal sphincter injuries (OASIs) using our unit’s standardised protocol. Our secondary objectives were to evaluate the role of internal anal sphincter defects and also to compare outcomes in a subgroup of symptomatic women with normal anorectal physiology.MethodsThis is a prospective follow-up study of pregnant women with previous OASIs who were counselled regarding subsequent mode of delivery between January 2003 and December 2014. Assessment involved the St Mark’s Incontinence Score (SMIS), anal manometry and EAUS at both antepartum and 3-month postpartum visits. Data were analysed using Wilcoxon and Mann–Whitney U tests.ResultsThree hundred and fifty women attended the perineal clinic over the study period, of whom 122 met the inclusion criteria (99 vaginal delivery [VD], 23 caesarean section). No significant worsening of anorectal symptoms was observed following subsequent delivery in the VD group (p = 0.896), although a reduced squeeze pressure was observed at 3 months postpartum (p < 0.001). There were no new defects on EAUS in either group.ConclusionsThis study showed no significant worsening of bowel symptoms and sphincter integrity apart from lower squeeze pressures at 3 months postpartum in the VD group when our standardised protocol was used to recommend subsequent mode of delivery. In the absence of a randomised study, use of this protocol can aid clinicians in their decision-making.

It is the first birth that does the damage: a cross-sectional study 20years after delivery.

Levator ani muscle (LAM) and anal sphincter tears are common after vaginal birth and are associated with female pelvic organ prolapse and anal incontinence. The impact of subsequent births on LAM and external anal sphincter (EAS) integrity is less well defined. The objective of this study was to determine the prevalence of LAM and EAS trauma in primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally to assess if there were differences between the two groups. The null hypothesis was: there is no significant difference in the prevalence of LAM and EAS trauma between the two groups. This was a cross-sectional study involving 195 women, participants of the Dunedin arm of the ProLong study (PROlapse and incontinence LONG-term research study) seen 20years after their index birth. Assessment included a standardized questionnaire, ICS POP-Q and 4D translabial ultrasound. Post-imaging analysis of LAM and EAS integrity was undertaken blinded against other data. Statistical analysis was performed using Fisher's exact test and results were expressed as odds ratios (OR). LAM avulsion and EAS defects were diagnosed in 31 (16%) and 24 (12.4%) women respectively. No significant difference in the prevalence of levator avulsion and EAS defects between primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally (OR 1.9, 95% CI 0.72-5.01, p = 0.26) and (OR 1.2, 95% CI 0.4-3.8, p = 0.76) respectively. Most LAM avulsions and EAS defects seem to be caused by the first vaginal birth. Subsequent vaginal deliveries after the first were unlikely to cause further LAM trauma.

In ineffective esophageal motility, failed swallows are more functionally relevant than weak swallows.

Esophageal pressure topography (EPT) diagnosis of ineffective esophageal motility (IEM) can be non-specific with unclear clinical significance. To determine whether peristaltic vigor or lower esophageal sphincter (LES) integrity is associated with poor clearance and acid reflux in IEM. Bolus clearance on high-resolution impedance manometry (HRIM) and available reflux studies in patients with IEM were retrospectively reviewed. Bolus clearance was assessed using both line tracing and colored contour methods on HRIM. EPT parameters, bolus clearance, and acid reflux variables were explored. Eighty-eight patients with IEM were included. Bolus clearance occurred in 71% of all swallows, and 55.7% of patients had complete bolus transit (CBT, bolus clearance in ≥80% of swallows). Bolus clearance was impaired in swallows with distal contractile integral (DCI) <100mmHg•cm•s compared to DCI 100-450 (0.43 vs 0.79, P<.0001). A cutoff at DCI 100mmHg•cm•s was associated with clearance with an accuracy of 76% compared to 49% at DCI 450 (P=.0001 for both). A median DCI <100 was associated with a higher Eckardt score (9 vs 3, P=.03), and on reflux testing available in 47 patients, with abnormal acid exposure time (P=.002). Peristaltic reserve (PR) defined as (DCI of multiple rapid swallow/median DCI of wet swallows), integrated relaxation pressure, and resting lower esophageal sphincter pressure were not associated with clearance or acid exposure. Failed peristalsis, as defined by DCI <100mmHg•cm•s, is associated with impaired bolus clearance and more severe dysphagia in IEM, and likely abnormal acid exposure.

Sa1662 - In Ineffective Esophageal Motility, Failed Swallows are More Functionally Relevant than Weak Swallows

BACKGROUND Esophageal pressure topography (EPT) diagnosis of ineffective esophageal motility (IEM) can be non-specific with unclear clinical significance. AIMS To determine whether peristaltic vigor or lower esophageal sphincter (LES) integrity is associated with poor clearance and acid reflux in IEM. METHODS Bolus clearance on high-resolution impedance manometry (HRIM) and available reflux studies in patients with IEM were retrospectively reviewed. Bolus clearance was assessed using both line tracing and colored contour methods on HRIM. EPT parameters, bolus clearance, and acid reflux variables were explored. KEY RESULTS Eighty-eight patients with IEM were included. Bolus clearance occurred in 71% of all swallows, and 55.7% of patients had complete bolus transit (CBT, bolus clearance in ≥80% of swallows). Bolus clearance was impaired in swallows with distal contractile integral (DCI) <100 mmHg•cm•s compared to DCI 100-450 (0.43 vs 0.79, P < .0001). A cutoff at DCI 100 mmHg•cm•s was associated with clearance with an accuracy of 76% compared to 49% at DCI 450 (P = .0001 for both). A median DCI <100 was associated with a higher Eckardt score (9 vs 3, P = .03), and on reflux testing available in 47 patients, with abnormal acid exposure time (P = .002). Peristaltic reserve (PR) defined as (DCI of multiple rapid swallow/median DCI of wet swallows), integrated relaxation pressure, and resting lower esophageal sphincter pressure were not associated with clearance or acid exposure. CONCLUSIONS & INFERENCES Failed peristalsis, as defined by DCI <100 mmHg•cm•s, is associated with impaired bolus clearance and more severe dysphagia in IEM, and likely abnormal acid exposure.

Waist to hip ratio is a better predictor of esophageal acid exposure than body mass index.

Obesity and gastroesophageal reflux disease (GERD) are major health problems showing an inconstant relationship in the literature. Therefore, anthropometric parameters which are predictive and can simply be assessed at first patient presentation may lead to a better patient selection for ambulatory reflux monitoring. We aimed to examine the association of body mass index (BMI) and waist to hip ratio (WHR) with gastroesophageal reflux activity during 24hour-pH-impedance monitoring. Seven hundred and seventy-one patients with GERD symptoms underwent 24hour-pH-impedance monitoring and high resolution manometry off proton pump inhibitors. Patients with known primary motility disorders of the esophagus and pre-existing endoscopic or operative procedure on esophagus or stomach were excluded from the study. Reflux parameters and anthropometric and demographic data from our prospectively gathered database were analyzed. We performed univariate and multivariate regression analysis to evaluate the associations of BMI and WHR with reflux parameters measured with 24hour-pH-impedance monitoring. WHR showed a significantly stronger association with esophageal acid exposure than BMI (P<.001). Our data show that 6.9% of the percentage of endoluminal pH<4 in the distal esophagus is attributable to WHR. Furthermore, an association of WHR with impaired esophageal acid clearance was observed. Additionally, we observed an inverse relationship between lower esophageal sphincter integrity (P=.05) and esophageal acid exposure. WHR is a better predictor for esophageal acid exposure than BMI. Biomechanical and metabolic mechanisms of central fat distribution may influence reflux parameters in 24hour pH impedance monitoring, which may affect patient selection for ambulatory reflux monitoring.

Modified Kegel exercise regimen following definitive and adjuvant prostate cancer radiotherapy.

e629 Background: 5-15% of patients treated with curative radiotherapy for prostate cancer experience some degree of urinary or fecal leakage. We hypothesized that a regimen of postradiotherapy perineal exercises would reduce this problem of sphincter dysfunction Methods: Upon completion of either conformal- or intensity-modulated radiotherapy to 76 Gy in 38 fractions (definitive) or 66 Gy in 33 fractions (postprostatectomy) patients were advised to commence a life-long program of daily perineal strengthening exercises. This consisted of a modified Kegel regimen for 5 minutes at a time, four times daily, and continued indefinitely. Patients have been monitored in regard to compliance and sphincter dysfunction at scheduled cancer clinic followup visits as well as by telephone survey. Results: 530 patients have been engaged in this postradiotherapy sphincter conditioning program. Parameters being analyzed are compliance with the regimen, frequency of exercise performance, urinary and fecal incontinence rates Conclusions: Pending the final tabulation of results the practical feasibility of such a prophylactic perineal exercise regimen as well as its impact on post radiotherapy sphincter integrity will be ascertained.

Does anal sphincter injury preclude subsequent vaginal delivery?

ObjectiveTo assess continence and anal sphincter integrity during a subsequent pregnancy and delivery in women known to have a previous anal sphincter injury. DesignProspective observational study. SettingThe National Maternity Hospital, Dublin, Ireland. PopulationAntenatal patients with a documented obstetric anal sphincter injury at a previous delivery. MethodsWomen underwent symptom scoring, endoanal ultrasound and manometry. Main outcome measuresRecommended and actual mode of delivery, continence scores and endoanal ultrasound findings after index delivery. Results557 women were studied. 293 (53%) had no symptoms of faecal incontinence, 189 (34%) had mild symptoms and 75 (13%) moderate or severe symptoms.408 (73%) had an endoanal ultrasound. 383(94%) had a normal or small (<1 quadrant) defect in the internal anal sphincter and 390 (96%) had a scar or small (<1e quadrant) defect in the external anal sphincter.393 (70%) delivered vaginally. 164 (30%) were delivered by caesarean section. 197/557 (35%) returned for follow-up. There was no significant change in continence following either vaginal or caesarean delivery. 20 (5.1%) women had a recognised second anal sphincter tear during vaginal delivery. ConclusionsThe majority of women who sustain a third degree tear have minimal or no symptoms of faecal incontinence when assessed antenatally in a subsequent pregnancy. 70% go on to have a vaginal delivery, with little impact on faecal continence. These findings provide reassurance for patients and clinicians about the safety of vaginal delivery following anal sphincter injury in appropriately selected patients.

Delayed absorbable synthetic plug (GORE® BIO-A®) for the treatment of fistula-in-ano: a systematic review.

Recent advances in the treatment of fistula-in-ano have focused on surgical techniques that preserve sphincter integrity. Plugs that obliterate the lumen of the fistula track have been proposed as one such method, and may be derived from biological or delayed absorbable synthetic materials. Biological plugs have highly variable results and have not been widely adopted. The aim of this systematic review was to assess the effectiveness and safety of a delayed absorbable synthetic plug (GORE® BIO-A®) for treatment of anal fistula. A systematic review of all literature in the English language relevant to the use of a plug to treat anal fistula and published between 1 January 2008 and 15 February 2015 was carried out by searching MEDLINE, EMBASE and the Cochrane Library of Systematic Reviews/Controlled Trials for relevant literature. Relevant articles were identified, quality assessed using the methodological index for nonrandomized studies criteria and data were extracted by two independent researchers (SKN and NNA). The identified articles were assessed with regard to fistula healing rate, duration of follow-up and complication rates related to the use of delayed absorbable synthetic fistula plugs. Twenty six potential articles were identified from the literature search. Using the predefined inclusion and exclusion criteria, six were included in the final analysis, data extraction and data synthesis. Of these included in the review only three were prospective in design. Complete data were available for 187 of the 221 patients who underwent this treatment. The age of the participants ranged from 19 to 82years. The fistula healing rates were reported to be between 15.8% and 72.7% at a follow-up ranging between 2 and 19months. Early or delayed plug extrusion occurred in 16 (8.5%) of the 187 patients. Deterioration in continence was reported in 11 (5.8%) of 187 patients. There are insufficient high-quality data on the delayed absorbable synthetic (GORE® BIO-A®) fistula plug to draw meaningful conclusions regarding its effectiveness. It does, however, appear to be a simple and safe technique associated with low complication rates and a minor deterioration in continence in a few cases.

Two-dimensional Endoanal Ultrasound Scan Correlates with External Anal Sphincter Structure and Function, but not with Puborectalis

BackgroundTo investigate the relevance of two-dimensional (2D) endoanal ultrasonic (EAUS) assessment of anal sphincter and puborectalis morphology by comparison to functional measures derived from patient symptoms and anorectal physiology. MethodsThirty women (mean age 44 years, mean parity 2) with anal incontinence underwent 2D EAUS, anorectal pull-through manometry, anorectal electosensitivity and sensation to rectal distension, pelvic floor dynamometry, and completed Wexner incontinence scores. EAUS images were reported blind to physiological assessments by a single experienced observer. The external and internal sphincters, and puborectalis were measured and scored for integrity and atrophy, and correlated with symptom load (Wexner score) and physiological data. ResultsThe mean Wexner score was 10 (range 1–20). The puborectalis could not be accurately measured in 12 patients (44%) on EAUS. Anal squeeze pressure correlated with integrity of the external sphincter (r = −0.4, p = 0.02) but not integrity or atrophy of the puborectalis. There were no other significant correlations between EAUS features and patient symptom load or anorectal physiology (r range, −0.42–0.26, p > 0.05). ConclusionTwo-dimensional EAUS can define sphincter integrity, has a limited role for assessment of muscular quality but is not useful for assessment of the puborectalis.

3D High Resolution Anal Manometry (3DHRAM) on Squeeze Estimates Anal Sphincter Length and Lengths Correlate With Symptoms of Constipation and Fecal Incontinence

Introduction: Constipation and fecal incontinence (FI) are common anorectal disorders, affecting 20% and 8% of the population respectively. Anorectal manometry is a diagnostic modality that assesses function of the anorectum. Addition of 3D HRAM may improve diagnostic value by better illustration of sphincter function and integrity. There is some evidence that 3D manometry catheters, a fixed type of catheter, differ from traditional catheter measurements. We explored value of 3D images in estimating anal sphincter length. Our hypothesis is that the estimated length of anal sphincter is related to symptoms, and that FI patients would have shorter sphincters. Methods: We obtained IRB approval for a retrospective review of 3D-HRAM of clinical studies conducted between Jan 2013 and May 2015 for either FI or constipation, at Johns Hopkins Motility Center. We recorded demographic data. We analyzed 30 3DHRAM studies using ManoView ® software to sequentially review 3D images through baseline, rest, squeeze and bear down. We estimated the length of anal sphincter by measuring the maximum number of sensors with pressure greater than 80 mmHg on 3D imaging during squeeze frame, and multiplying by the distance between sensors (0.4cm). Results: Anal sphincter length for constipated patients on average was 3.85 cm and for those with FI was on average 2.69. This was statistically significant (p value = 0.013). Similarly, mean resting HPZ was 4.13cm for constipated subjects vs 2.85 cm for FI subjects (P value < 0.001). There was no significant difference in age distribution between the groups (correlation factor 0.12) or height (-0.15). Conclusion: The anal sphincter is involved in control of bowel habits, and the size and continuity of the anal sphincter likely related to strength and function. Shorter length of anal sphincter on 3D view during squeeze appears to be correlated with symptoms of FI, and longer length appears to be correlated with constipation. The true value of 3D anorectal manometry is under investigation, but this pilot study offers a glimpse at the role of 3D HRAM in interpretation of anorectal disorders. Further research can determine if this correlation is predictive of patient symptoms.

Impact of Patient Age on Procedure Type for Ulcerative Colitis: A National Study.

Historically, older patients with ulcerative colitis were not considered candidates for ileal pouch-anal anastomosis. However, more recent evidence suggests that this procedure can be performed in older patients with acceptable surgical and functional results. The purpose of this work was to determine whether older age is independently associated with surgical procedure type among patients with ulcerative colitis in a large national database. This was a cross-sectional analysis of ulcerative colitis patients undergoing end ileostomy or IPAA, grouped by age. This study was conducted in a university teaching hospital. Patients with ulcerative colitis who underwent total proctocolectomy or completion proctectomy with either IPAA or end ileostomy from 2005 to 2012 in the American College of Surgeons National Surgery Quality Improvement Program database were included in this study. The primary outcome was procedure type (end ileostomy or IPAA). Patient factors associated with procedure type, including age and trends over time, were examined using multivariate logistic regression. Among 3635 patients with ulcerative colitis, 28.2% underwent end ileostomy and 71.8% underwent IPAA. Older patients were more likely to undergo end ileostomy than patients ≤50 years of age after adjustment for sex, smoking, BMI, frailty trait count, and ASA class (p < 0.001). The odds of end ileostomy decreased by 12% per year between 2005 and 2012 in patients aged 61 to 70 years compared with patients ≤50 years of age (adjusted OR, 0.88 per year; p = 0.021). We were unable to analyze other potentially important determinants of procedure type, such as surgeon, patient preference, and anal sphincter integrity. Age remains strongly associated with procedure type. The use of end ileostomy, however, is decreasing over time in patients 61 to 70 years of age as evidence accumulates that IPAA is an acceptable option for older patients with ulcerative colitis (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A191).

Screening occult anal sphincter injuries in primigravid women after vaginal delivery with transperineal use of vaginal probe: a prospective, randomized controlled trial.

Here we aimed to evaluate the incidence of obstetric anal sphincter injuries in spontaneous primigravid deliveries with mediolateral episiotomy beyond 36 gestational weeks. We performed a prospective, randomized controlled study including 201 primigravid women that delivered vaginally. Anal sphincter anatomy and integrity was evaluated before hospital discharge in all cases with transvaginal sonography (5-9MHz) (Siemens Sonoline G50 and Voluson 730 Expert). The vaginal ultrasound probe is placed in the fourchette of the vaginal introitus to obtain the transverse section of the anal sphincter. In the cases with sphincter defect, mean gestational week and second stage of labor were prolonged significantly (p=0.039 and p<0.0001, respectively). The mean perineal body distance in cases with sphincter injury, as detected by sonography, 2.18±0.33cm, is compared to 2.31±2.43cm in cases without injury. There was a significant difference between the two groups (p=0.0142). Shoulder dystocia was significantly higher in cases with sphincter injury, compared to cases without injury (p=0.011). No clinical findings were reported in 11.5% of cases (Sonography findings 1A∓, 1B∓) and 3.5% of cases had clinical and sonographic findings (Sonography findings 2A∓, 2B∓). "Occult tears" were considered as those cases not detected clinically, but detected by sonography (11.5% of all cases). Two months after examination, a moderate incontinence (Wexner continence scale) was found in 71.5% of cases with overt sphincter tear, which was significantly different to the non-overt sphincter tear group. Multiple logistic regression analyses for sphincter injuries identified prolonged second stage of labor and shoulder dystocia as two independent risk factors. Here, we found that only a portion of anal sphincter injuries can be detected after physical examination, with many of cases of "occult tears" escaping notice. These cases of occult anal sphincter injury are detectable by sonography with transperineal use of a vaginal probe. Based on these findings, we propose that this technique is convenient for obstetric, gynecologic and proctologic evaluation of sphincter anatomy.

Effect of endorectal pullthrough on external anal sphincter integrity (in cases of Hirchsprung’s disease) using EMG

ObjectiveThe transanal mucosectomy of the aganglionic segment is a critical step in the transanal endorectal pullthrough procedure for the treatment of Hirchsprung’s disease. It exerts considerable traction on the anorectal tissue during dissection. Anal sphincter electromyography (EMG) is an indisp

Magnetic resonance imaging in assessment of stress urinary incontinence in women: Parameters differentiating urethral hypermobility and intrinsic sphincter deficiency.

To define the magnetic resonance imaging (MRI) parameters differentiating urethral hypermobility (UH) and intrinsic sphincter deficiency (ISD) in women with stress urinary incontinence (SUI). The static and dynamic MR images of 21 patients with SUI were correlated to urodynamic (UD) findings and compared to those of 10 continent controls. For the assessment of the urethra and integrity of the urethral support structures, we applied the high-resolution endocavitary MRI, such as intraurethral MRI, endovaginal or endorectal MRI. For the functional imaging of the urethral support, we performed dynamic MRI with the pelvic phased array coil. We assessed the following MRI parameters in both the patient and the volunteer groups: (1) urethral angle; (2) bladder neck descent; (3) status of the periurethral ligaments, (4) vaginal shape; (5) urethral sphincter integrity, length and muscle thickness at mid urethra; (6) bladder neck funneling; (7) status of the puborectalis muscle; (8) pubo-vaginal distance. UDs parameters were assessed in the patient study group as follows: (1) urethral mobility angle on Q-tip test; (2) Valsalva leak point pressure (VLPP) measured at 250 cc bladder volume; and (3) maximum urethral closure pressure (MUCP). The UH type of SUI was defined with the Q-tip test angle over 30 degrees, and VLPP pressure over 60 cm H2O. The ISD incontinence was defined with MUCP pressure below 20 cm H2O, and VLPP pressure less or equal to 60 cm H2O. We considered the associations between the MRI and clinical data and UDs using a variety of statistical tools to include linear regression, multivariate logistic regression and receiver operating characteristic (ROC) analysis. All statistical analyses were performed using STATA version 9.0 (StataCorp LP, College Station, TX). In the incontinent group, 52% have history of vaginal delivery trauma as compared to none in control group (P < 0.001). There was no difference between the continent volunteers and incontinent patients in body habitus as assessed by the body mass index. Pubovaginal distance and periurethral ligament disruption are significantly associated with incontinence; periurethral ligament symmetricity reduces the odds of incontinence by 87%. Bladder neck funneling and length of the suprapubic urethral sphincter are significantly associated with the type of incontinence on UDs; funneling reduced the odds of pure UH by almost 95%; increasing suprapubic urethral sphincter length at rest is highly associated with UH. Both MRI variables result in a predictive model for UDs diagnosis (area under the ROC = 0.944). MRI may play an important role in assessing the contribution of hypermobility and sphincteric dysfunction to the SUI in women when considering treatment options.

Endosonography and magnetic resonance imaging in the diagnosis of high anal fistulae - a comparison.

Anal fistula is a benign inflammatory disease with unclear etiology which develops in approximately 10 in 100 000 adult patients. Surgical treatment of fistulae is associated with a risk of damaging anal sphincters. This usually happens in treating high fistulae, branched fistulae, and anterior ones in females. In preoperative diagnosis of anal fistulae, endosonography and magnetic resonance imaging play a significant role in planning the surgical technique. The majority of fistulae are diagnosed in endosonography, but magnetic resonance is performed when the presence of high fistulae, particularly branched ones, and recurrent is suspected.The aim of this paperThe aim of this paper was to compare the roles of the two examinations in preoperative assessment of high anal fistulae.Material and methodsThe results of endosonographic and magnetic resonance examinations performed in 2011–2012 in 14 patients (4 women and 10 men) with high anal fistulae diagnosed intraoperatively were subject to a retrospective analysis. The patients were aged from 23 to 66 (mean 47). The endosonographic examinations were performed with the use of a BK Medical Pro Focus system with endorectal 3D transducers with the frequency of 16 MHz. The magnetic resonance scans were performed using a Siemens Avanto 1.5 T scanner with a surface coil in T1, T1FS, FLAIR, T2 sequences and in T1 following contrast medium administration. The sensitivity and specificity of endosonography and magnetic resonance imaging were analyzed. A surgical treatment served as a method for verification. The agreement of each method with the surgery and the agreement of endosonography and magnetic resonance imaging were compared in terms of the assessment of the fistula type, localization of its internal opening and branches. The agreement level was determined based on the percentage of consistent assessments and Cohen's coefficient of agreement, κ. The integrity of the anal sphincters was assessed in each case.ResultsIn determining the fistula type, magnetic resonance imaging agreed with intraoperative assessment in 79% of cases, and endosonography in 64% of cases. Endosonography agreed with magnetic resonance in 57% of cases. In the assessment of internal opening, the agreement between endosonography and intraoperative assessment was 65%, between magnetic resonance and intraoperative assessment – 41% and between endosonography and magnetic resonance – 53%. In the assessment of fistula branches, endosonography agreed with intraoperative assessment in 67% of cases, magnetic resonance in 87% of cases, and the agreement between the two methods tested was 67%.ConclusionsMagnetic resonance is a more accurate method than endosonography in determining the type of high fistulae and the presence of branches. In assessing the internal opening, endosonography proved more accurate. The agreement between the two methods ranges from 53–67%; the highest level of agreement was noted for the assessment of branching.

Sacral Nerve Stimulation for the Treatment of Severe Faecal Incontinence: Results After 10 Years Experience

IntroductionThe objective of this study was to report our experience with sacral nerve stimulation for the treatment of severe faecal incontinence after the first 10 years with this technique. Materials and methodsBetween 2001 and 2011, 49 patients with severe faecal incontinence underwent sacral nerve stimulation. Anorectal manometry, endoanal ultrasound and pudendal nerve latency were performed. Bowel habit diary, severity of faecal incontinence and quality of life scales were evaluated preoperatively and at the end of follow-up. ResultsMorbidity occurred in a third of patients, mostly minor. Four definitive devices were explanted. With a median follow-up of 37 months, severity of faecal incontinence, urge and incontinence episodes significantly improved at the end of follow-up. Patients’ subgroup with a major follow-up of 5 years significantly improved the severity of faecal incontinence but not the parameters of the bowel habit diary. Quality of life showed no significant improvement. Descriptive data of patients with sphincter defects did not show worse results than that of patients with sphincter integrity. ConclusionSacral nerve stimulation is a safe technique for severe faecal incontinence with good functional medium-term results. In the long term, severity of the faecal incontinence also improves, but studies with larger sample are necessary to show if other clinical parameters and the quality of life support this information. Preliminary results in patients with sphincter defects suggest that this technique could be effective in this group, but future studies will have to confirm these findings.

Neuromodulación sacra en el tratamiento de la incontinencia fecal grave: resultados tras 10 años de experiencia

IntroductionThe objective of this study is to report our experience with sacral nerve stimulation for the treatment of severe faecal incontinence after the first 10 years with this technique. Material and methodsBetween 2001 and 2011, 49 patients with severe faecal incontinence underwent sacral nerve stimulation. Anorectal manometry, endoanal ultrasound and pudendal nerve latency were performed. Bowel habit diary, severity of faecal incontinence and quality of life scales were evaluated preoperatively and at the end of follow-up. ResultsMorbidity occurred in a third of patients, mostly minor. Four definitive devices were explanted. With a median follow-up of 37 months, severity of faecal incontinence, urge and incontinence episodes significantly improved at the end of follow-up. Patients’ subgroup with major follow-up of 5 years significantly improved the severity of faecal incontinence but not the parameters of the bowel habit diary. Quality of life showed no significant improvement. Descriptive data in patients with sphincter defects did not show worse results than with sphincter integrity. ConclusionSacral nerve stimulation is a safe technique for severe faecal incontinence with good functional medium-term results. In the long term, severity of the faecal incontinence also improves but studies with larger sample are necessary to show if other clinical parameters and the quality of life support this information. Preliminary results in patients with sphincter defects suggest that this technique could be effective in this group but future studies will have to confirm these findings.

Imaging of the Pelvic Floor

Urinary continence depends on, an intact internal urethral sphincter (IUS) with a high alpha-sympathetic tone gained by learning in childhood both create high urethral pressure. The IUS is a collagen-muscle tissue cylinder that extends from the bladder neck to the perineal membrane in both sexes. Childbirth trauma causes injury to the vagina and the intimately lying IUS. It lacerates the collagen frame of the IUS. A weak torn IUS will not stand sudden rise of abdominal pressure and urine leaks, stress urinary incontinence (SUI). Imaging with three-dimension ultrasound (3DUS) and MRI demonstrate the torn IUS and show the site and extent of the injury. Torn upper part of the IUS causes funneling and apparent descent of the bladder neck and leads to overactive bladder. Torn lower part leads to genuine SUI. Injury to the whole length leads to mixed- type of urinary incontinence and apparent shortening of the urethra with collapsed torn walls. Fecal continence depends on a closed anal canal that depends on the integrity of both anal sphincters, the internal anal sphincter (IAS) and the external anal sphincter (EAS). It also depends on intact reactive nervous system and on an acquired high alpha-sympathetic tone at the IAS gained by training in early childhood. The IAS is a collagen-muscle tissue cylinder that surrounds the anal canal with the EAS surrounds it in its lower part. Torn EAS is obvious, but only imaging with 3DUS and MRI show an open anal canal with torn IAS in cases of fecal incontinence. Keywords: Collagen, internal urethral sphincter (IUS), internal anal sphincter (IAS), three dimension ultrasound (3DUS), magnetic resonance imaging (MRI).Collagen, internal urethral sphincter (IUS), internal anal sphincter (IAS), three dimension ultrasound (3DUS), magnetic resonance imaging (MRI).