Symptoms Of Anal Incontinence Research Articles

Perineoplasty for anal incontinence after obstetric anal sphincter injury repair: a case report

BackgroundThe rectal and vaginal walls are typically sutured if severe perineal lacerations with rectal mucosal damage occur during vaginal delivery. In case of anal incontinence after the repair, re-suturing of the anal sphincter muscle is standard procedure. However, this procedure may not result in sufficient improvement of function.Case presentationA 41-year-old woman underwent suture repair of the vaginal and rectal walls for fourth-degree perineal laceration at delivery. She was referred to our department after complaining of flatus and fecal incontinence. Her Wexner score was 15 points. Examination revealed decreased anal tonus and weak contractions on the ventral side. We diagnosed anal incontinence due to sphincter dysfunction after repair of a perineal laceration at delivery. We subsequently performed sphincter re-suturing with perineoplasty to restructure the perineal body by suturing the fascia located lateral to the perineal body and running in a ventral–dorsal direction, which filled the space between the anus and vagina and increased anal tonus. One month after surgery, the symptoms of anal incontinence disappeared (the Wexner score lowered to 0 points), and the anorectal manometry values increased compared to the preoperative values. According to recent reports on the anatomy of the female perineal region, bulbospongiosus muscle in women does not move toward the midline to attach to the perineal body, as has been previously believed. Instead, it attaches to the ipsilateral surface of the external anal sphincter. We consider the fascia lateral to the perineal body to be the fascia of the bulbospongiosus muscle.ConclusionsIn a case of postpartum anal incontinence due to sphincter dysfunction after repair of severe perineal laceration, perineoplasty with re-suturing an anal sphincter muscle resulted in improvement in anal sphincter function. Compared to conventional simple suture repair of the rectal wall only, this surgical technique may improve sphincter function to a greater degree.

Defecatory dysfunction and anal incontinence symptoms among women with pelvic organ prolapse: 5-year retrospective study in a tertiary center.

To investigate the prevalence of DD and AI with POP symptoms in females attending a urogynecology clinic, and to identify factors associated with DD and AI in POP symptoms patients. Computer-based medical records of women with POP symptoms attending a urogynecology clinic in a referral tertiary center between January 2016 and December 2020 were reviewed. Demographic data were collected. Selected defecatory dysfunction (DD) and anal incontinence (AI) were recorded. The associations between patient characteristics, site and severity of prolapse, and DD and AI symptoms in POP patients were investigated for identified associated factors. The mean age of the 754 participants was 65.77 ± 9.44years. Seven hundred and fifteen (94.83%) were menopause. The prevalence of DD and AI in patients with POP symptoms was 44.03% (332/754) and 42.04% (317/754) according to the PFBQ and medical history records, respectively. Advanced posterior wall prolapse (OR 1.59, 95% CI 1.10-2.30) and wider GH (OR1.23, 95% CI 1.05-1.43) were identified as risk factors for DD by multivariate analysis. Additionally, single-compartment prolapse (OR 0.4, 95% CI 0.21-0.76) and a stronger pelvic floor muscle assessed with brink score (OR 0.94, 95% CI 0.88-0.98) are protective factors for AI. DD and AI are prevalent among women with POP symptoms who visit a urogynecology clinic. DD should be evaluated in women with POP symptoms especially in women with increased genital hiatus and point Ap beyond the hymen. To prevent AI, women with POP should be encouraged to perform pelvic floor muscle training in order to increase pelvic floor muscle strength.

Pelvic floor muscle training in female functional fitness exercisers: an assessor-blinded randomised controlled trial

ObjectiveStress urinary incontinence (SUI) is common among females during functional fitness training, such as CrossFit. The aim of this study was to assess the effect of pelvic floor muscle training...

Results of a Systematic Intensive Follow-Up of 259 Cases of Obstetric Anal Sphincter Injury

BACKGROUND:Obstetric anal sphincter injury (OASI) is a complication of childbirth. Some women will develop symptoms, which may appear in the short or long term. In most clinical practice guidelines, follow-up is only recommended in women with anal incontinence (AI). In our hospital, follow-up is offered to all women who suffer an OASI: Anorectal manometry (ARM) and endoanal ultrasound (EAUS) are scheduled for all patients. The aim of this study was to determine if a symptom-based or systematic follow-up was better for these patients. To do so, we compared the results of investigations (EAUS and ARM) between asymptomatic and symptomatic women.METHODS:A retrospective analysis of prospectively collected data from 259 women who suffered an OASI in a single tertiary hospital in Barcelona (Spain) between May 2008 and May 2018.RESULTS:Seventy-seven percent of women attended the first follow-up visit at the perineal clinic, and 40.5% of women completed the 12-month follow-up. At initial evaluation, 60% of the patients had a Wexner score of 0. Seventy-two percent of women had an abnormal result on one or both investigations (EAUS and ARM).CONCLUSIONS:Attendance and adherence to our follow-up protocol are low. Although the incidence of AI symptoms is low at early follow-up in women after OASI, they show a high rate of functional dysfunctions on manometry. If follow-up is offered only to symptomatic patients, it could lead to an underestimation of their true condition.

Development and Validation of a Tool to Identify Anal Incontinence in Pregnant and Postnatal Women.

Neuromuscular and mechanical damage to the pelvic floor because of pregnancy and birth can result in anal incontinence. Pregnant and postnatal women are rarely screened for anal incontinence by clinicians who specialize in the care of these women, and no screening tool has been developed for routine use in these women. To develop and validate a tool for use in everyday clinical practice in the care of pregnant and postnatal women. The study includes 2 test phases with separate data sources. Phase I included test and retest phases of the Bowel-Screening Questionnaire in health professionals and women who were pregnant or had recently birthed (n = 45). Phase II included a pilot of the tool compared to 2 current scoring systems (n = 358). Large tertiary hospital in South Australia. Phase II: prospective recruitment of 358 prenatal parous women attending a first antenatal appointment. To evaluate the reliability and validity of the developed tool. Test-retest agreement in phase I was excellent for each of the 6 items, with each κ statistic being between 0.83 and 1.0. In phase II, agreement between new and existing tools was fair to good for the detection of anal incontinence symptoms addressed as a composite question (κ between 0.41 and 0.71). Anal incontinence was detected in 191 women (53%) using the new tool, and there was a lower prevalence reported using the Vaizey score (n = 118) and Wexner score (n = 129). Completion rates of the new tool were 99%, higher than both the Vaizey score (33%) and Wexner score (36%). Sample size limits the generalization of findings. The questionnaire is reliable and valid, reporting a high incidence of bowel incontinence, with predominant symptoms of rectal urgency and flatus as precursors for worsening function. ANTECEDENTES:El daño neuromuscular y mecánico del piso pélvico debido al embarazo y al parto puede resultar en incontinencia anal. Las mujeres embarazadas y puérperas rara vez son examinadas para la incontinencia anal por médicos que se especializan en el cuidado de estas mujeres, y no se ha desarrollado ninguna herramienta de detección para uso rutinario en estas mujeres.OBJETIVO:Desarrollar y validar una herramienta para uso en la práctica clínica diaria en el cuidado de las mujeres embarazadas y puérperas.FUENTES DE DATOS:El estudio incluye 2 fases de prueba con fuentes de datos separadas. Fase 1, fase test y retest del Bowel Screening Questionnaire en profesionales sanitarios y mujeres embarazadas o recién paridas (n = 45). La Fase 2 incluyó una prueba piloto de la herramienta en comparación con dos sistemas de puntuación actuales (n = 358).ENTORNO CLINICO:Gran hospital terciario en el sur de Australia.PACIENTES:Fase 2: reclutamiento prospectivo de 358 mujeres con parto prenatal que asisten a una primera cita prenatal.PRINCIPALES MEDIDAS DE VALORACIÓN:Evaluar la confiabilidad y validez de la herramienta desarrollada.RESULTADOS:La concordancia test-retest en la fase 1 fue excelente para cada uno de los 6 ítems con cada estadística kappa entre 0,83 y 1,0. En la fase 2, el acuerdo entre las herramientas nuevas y las existentes fue regular a bueno para la detección de síntomas de incontinencia anal abordados como una pregunta compuesta (kappa entre 0,41 y 0,71). Se detectó incontinencia anal en 191 (53%) de las mujeres que utilizaban la nueva herramienta, y se notificó una prevalencia más baja utilizando la puntuación de Vaizey (n = 118) y la puntuación de Wexner (n = 129). Las tasas de finalización de la nueva herramienta fueron del 99%, más altas que la puntuación de Vaizey (33%) y las puntuaciones de Wexner (36%).LIMITACIONES:El tamaño de la muestra limita la generalización de los hallazgos.CONCLUSIONES:El cuestionario es confiable y válido reportando una alta incidencia de incontinencia intestinal, con síntomas predominantes de urgencia rectal y flatos como precursores del empeoramiento de la función. (Traducción-Dr. Ingrid Melo ).

Anal incontinence following obstetric anal sphincter injury: Is there a difference between subtypes? A systematic review.

Obstetric anal sphincter injury (OASI) is associated with long-term anal incontinence (AI). We aimed to address the following questions: (a) are women with major OASI (grade 3c and 4) at higher risk of developing AI when compared to women with minor OASI (grade 3a and 3b)? (b) is a fourth-degree tear more likely to cause AI over a third-degree tear? A systematic literature search from inception until September 2022. We considered prospective and retrospective cohort studies, cross-sectional and case-control studies without language restrictions. The quality was assessed by the Newcastle-Ottawa Scale and the Joanna Briggs Institute critical appraisal checklist. Risk ratios (RRs) were calculated to measure the effect of different grades of OASI. Out of 22 studies, 8 were prospective cohort, 8 were retrospective cohort, and 6 were cross-sectional studies. Length of follow-up ranged from 1 month to 23 years, with the majority of the reports (n = 16) analysing data within 12-months postpartum. Third-degree tears evaluated were 6454 versus 764 fourth-degree tears. The risk of bias was low in 3, medium in 14 and high in 5 studies, respectively. Prospective studies showed that major tears are associated with a twofold risk of AI for major tears versus minor tears, while retrospective studies consistently showed a risk of fecal incontinence (FI) which was two- to fourfold higher. Prospective studies showed a trend toward worsening AI symptoms for fourth-degree tears, but this failed to reach statistical significance. Cross-sectional studies with long-term (≥5 years) follow-up showed that women with fourth-degree tear were more likely to develop AI, with an RR ranging from 1.4 to 2.2. Out of 3, 2 retrospective studies showed similar findings, but the follow-up was significantly shorter (≤1 year). Contrasting results were noted for FI rates, as only 5 out of 10 studies supported an association between fourth-degree tear and FI. Most studies investigate bowel symptoms within few months from delivery. Data heterogeneity hindered a meaningful synthesis. Prospective cohort studies with adequate power and long-term follow-up should be performed to evaluate the risk of AI for each OASI subtype.

Is posterior compartment prolapse associated with anal incontinence?

It has been claimed that manifestations of posterior compartment prolapse, such as rectocele, enterocele and intussusception, are associated with anal incontinence (AI), but this has not been studied while controlling for anal sphincter trauma. We aimed to investigate this association in women with intact anal sphincter presenting with pelvic floor dysfunction. This retrospective study analyzed 1133 women with intact anal sphincter presenting to a tertiary urogynecological center for pelvic floor dysfunction between 2014 and 2016. All women underwent a standardized interview, including assessment of symptoms of AI, clinical examination and three-/four-dimensional transperineal ultrasound. Descent of the rectal ampulla, true rectocele, enterocele, intussusception and anal sphincter trauma were diagnosed offline. Mean age was 54.1 (range, 17.6-89.7)years and mean body mass index was 29.4 (range, 14.7-67.8) kg/m2 . AI was reported by 149 (13%) patients, with a median St Mark's anal incontinence score of 12 (interquartile range, 1-23). Significant posterior compartment prolapse was seen in 693 (61%) women on clinical examination. Overall, 638 (56%) women had posterior compartment prolapse on imaging: 527 (47%) had a true rectocele, 89 (7.9%) had an enterocele and 26 (2.3%) had an intussusception. Women with ultrasound-diagnosed enterocele had a significantly higher rate of AI (23.6% vs 12.3%; odds ratio (OR), 2.21 (95% CI, 1.31-3.72); P = 0.002), but when adjusted for potential confounders, this association was no longer significant (OR, 1.56 (95% CI, 0.82-2.77); P = 0.134). In women without anal sphincter trauma, posterior compartment prolapse, whether diagnosed clinically or by imaging, was not shown to be associated with AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Assessing Obstetric Anal Sphincter Injuries: A Comparison of Exoanal and Endoanal Ultrasound.

To explore the differences in assessing obstetric anal sphincter injuries (OASI) between transperineal ultrasound (TPUS) and endoanal ultrasound (EAUS) and test relationships between ultrasound findings and anal incontinence (AI) symptoms. A group of 196 women with a history of vaginal delivery was recruited. OASI was detected in a set of 5 slices by EAUS and 8 slices by TPUS. OASI grading was performed on TPUS rules and EAUS rules. A "significant sphincter defect" was diagnosed by TPUS and EAUS using "2/3 rules." Symptoms of AI were determined using the St Mark's Incontinence Score (SMIS). Ultrasound findings were compared between the two methods and correlated with symptoms. Of 196 women, 29 (14.8%) suffered from AI with a mean SMIS of 12.1 ± 4.5, and 70 (35.7%) women with a mean age of 57 years had suspected OASI on imaging. Twenty-one (10.7%) "significant defects" were diagnosed by TPUS and 24 (12.2%) by EAUS. OASI Grades on TPUS had good agreement with EAUS rules (k=0.70, P < .001). Logistic regression analysis showed that OASI Grade on imaging and "significant sphincter defects" seen on both forms of imaging were associated with AI symptoms. The odds ratio was 46 and 38 for "significant defects" on TPUS and EAUS, and 14 and 7 for OASI 3b+ on TPUS and EAUS in predicting AI, respectively. "Significant defects" diagnosed by EAUS or TPUS and OASI Grade 3b+ predict AI symptoms. The diagnostic performance of endoanal and exoanal ultrasound (EAUS and TPUS) appear to be very similar.

Urinary and anal incontinence in pregnancy in a Nigerian population: A prospective longitudinal study.

There are several studies from sub-Saharan Africa on postpartum urinary incontinence and anal incontinence, but very rare in pregnancy. Such data will guide obstetric caregivers in providing appropriate counseling to the women as well as in minimizing the risk factors. This study aimed to determine the comparative effects of different trimesters of pregnancy on urinary incontinence and anal incontinence, and their possible risk factors. The study was longitudinal in design, and the study population consisted of 223 pregnant women receiving care at the two largest tertiary health institutions in Enugu, South-East Nigeria. The recruitment was in the first trimester and the women were followed up to term. Interviews were conducted at specific times in the three trimesters and data regarding urinary incontinence and anal incontinence symptoms were obtained using validated questionnaires. The incidence of urinary incontinence increased across the trimesters: 22%, 30.5%, and 48% in the first trimester, second, and third trimesters, respectively, with a cumulative incidence rate of 50.2%. The incidence of anal incontinence also increased across the trimesters but not as high as urinary incontinence: 1.7%, 3.6%, and 5.8%, respectively, with a cumulative incidence rate of 6.7%. The risk factors for urinary incontinence were maternal age >35 years, multiparity, previous prolonged second-stage labor, and previous history of neonatal macrosomia, while that of anal incontinence were previous instrumental vaginal delivery and previous prolonged second stage of labor. Our study demonstrated an increase in the incidence of urinary incontinence and anal incontinence as pregnancy advances. Obstetricians are therefore encouraged to discuss these pelvic floor issues during antenatal care services and make more efforts toward reducing the modifying obstetric risk factors.

Transanal hemorrhoidal dearterialization (THD) for hemorrhoidal disease: An Italian single-institution 5-year experience analysis and updated literature review.

Hemorrhoidal disease is a highly prevalent, chronic disorder that usually compromise patients' quality of life. Despite recent advances in pharmacologic and surgical therapeutic options, a clear treatment "gold standard" is lacking. Our aim is to analyze the outcomes following Transanal Hemorrhoidal Dearterialization (THD) procedure. Patients who failed conservative treatment and underwent THD Doppler between 2017 and 2021 were enrolled. Follow-up interviews (consisting of clinical examination, Visual Analog Scale for pain-VAS, Vaizey incontinence score, Hemorrhoid Severity Score) were administered 1 week, 2weeks, 1 month and 6 months after surgery. Forty-seven out of 75 patients were male, and the mean age was 50 (±17.9) years. Hemorrhoids were classified as Goligher's degree II in 25 cases, III in 40 and IV, simple irreducible without ischemic changes, in 10. The mean operative time was 35 (28-60) minutes, and most procedures were performed with epidural anesthesia (80%). No intraoperative complications occurred, and 73 patients (97.3%) were discharged within post-operative day 1. Early post-operative pain and bleeding occurred in 37.3% and 8% of patients, respectively. No patients experienced anal incontinence and severe symptoms at 6 months after surgery. The overall success rate was 97.3%. THD is safe and effective in hemorrhoidal disease at degree II if bleeding, III, and IV without ischemic changes, both as a first intervention and on recurrence. Physician and patient need to understand each other's expectations, weight the risks and benefits, and customize the treatment.

Barriers and Promotors to Health Service Utilization for Pelvic Floor Disorders in the United States: Systematic Review and Meta-analysis of Qualitative and Quantitative Studies

(Abstracted from Urogynecology 2022;28:574–581) Pelvic floor disorders (PFDs), such as pelvic organ prolapse (POP), anal incontinence (AI), and lower urinary tract symptoms (LUTSs), affect approximately 1 in 4 women in the United States. Many women endure PFD symptoms without seeking care.

Obstetric anal sphincter injuries (OASIS): using transperineal ultrasound (TPUS) for detecting, visualizing and monitoring the healing process

PurposeThe aim of this study was to examine whether OASIS, and its extent, can be confirmed or excluded using transperineal ultrasound (TPUS). A further objective of this study was to monitor the healing process over a period of 6 months and to establish a connection between the sonographic appearance of obstetric anal sphincter injury (OASIS) and anal incontinence.Materials and methodsIn this retrospective clinical study, women with OASIS who gave birth between March 2014 and August 2019 were enrolled. All the patients underwent TPUS 3 days and 6 months after delivery. A GE E8 Voluson ultrasound system with a 3.5–5 MHz ultrasound probe was used. The ultrasound images showed a third-degree injury, with the measurement of the width of the tear and its extent (superficial, partial, complete, EAS and IAS involvement). A positive contraction effect, a sign of sufficient contraction, was documented. Six months after delivery, a sonographic assessment of the healing (healed, scar or still fully present) was performed. A Wexner score was obtained from each patient. The patients’ medical histories, including age, parity, episiotomy and child’s weight, were added.ResultsThirty-one of the 55 recruited patients were included in the statistical evaluation. Three patients were excluded from the statistical evaluation because OASIS was excluded on TPUS 3 days after delivery. One patient underwent revision surgery for anal incontinence and an inadequately repaired anal sphincter injury, as shown sonographic assessment, 9 days after delivery. Twenty patients were excluded for other reasons. The results suggest that a tear that appears smaller (in mm) after 3 days implies better healing after 6 months. This effect was statistically significant, with a significance level of alpha = 5% (p = 0.0328). Regarding anal incontinence, women who received an episiotomy had fewer anal incontinence symptoms after 6 months. The effect of episiotomy was statistically significant, with a significance level of alpha = 5% (p = 0.0367).ConclusionTPUS is an accessible, non-invasive method for detecting, quantifying, following-up and monitoring OASIS in patients with third-degree perineal tears. The width, as obtained by sonography, is important with regard to the healing of OASIS. A mediolateral episiotomy seems to prevent anal incontinence after 6 months.

Maternal and Neonatal Morbidity After Attempted Operative Vaginal Delivery.

To assess severe short-term maternal and neonatal morbidity and pelvic floor disorders at 6 months postpartum after attempted operative vaginal delivery according to the instrument used. We conducted a prospective study of women with live, singleton, term fetuses in vertex presentation. Patients attempted operative vaginal delivery in a French tertiary care university hospital from December 2008 through October 2013. We used multivariable logistic regression and propensity score methods to control for indication bias and compare outcomes associated with vacuum-assisted or forceps- or spatula-assisted delivery. Severe maternal and neonatal morbidity were composite primary endpoints. Symptoms of urinary incontinence (UI) and anal incontinence (AI) were assessed 6 months after delivery by validated self-administered questionnaires. Among 2,128 attempted operative vaginal deliveries, 30.7% (n=654) used vacuum and 69.3% (n=1,474) used forceps or spatulas. Severe maternal morbidity occurred in 5.4% (n=35; 95% CI 3.8-7.4) of vacuum attempts and 10.5% (n=154; 95% CI 8.3-12.1) of forceps or spatula attempts (P<.001); severe neonatal morbidity occurred in 8.4% (n=55; 95% CI 6.4-10.8) and 10.2% (n=155; 95% CI 8.7-11.8), respectively (P=.2). Although attempted operative vaginal deliveries with forceps or spatula were significantly associated with more frequent severe maternal morbidity (adjusted odds ratio [aOR] 1.99 95% CI 1.27-3.10) in the multivariable logistic regression analysis, this association was no longer significant after propensity score matching (aOR 1.46 95% CI 0.72-2.95). Attempted operative vaginal deliveries with forceps or spatula were not significantly associated with more frequent severe neonatal morbidity after multivariable logistic regression or propensity score matching. Among the 934 women (43.9%) who responded to questionnaires at 6 months, the prevalence of symptoms of UI and AI were 22.7% and 22.0%, respectively, with no significant differences between the groups. In singleton term pregnancies, neither severe short-term maternal or neonatal morbidity nor UI or AI were more frequent after attempted operative vaginal delivery by forceps or spatulas than by vacuum after controlling for indication bias with a propensity score analysis.

Vaginal Electrical Stimulation for Postpartum Neuromuscular Recovery: A Randomized Clinical Trial.

The aim of this study was to compare 3-month postpartum anal incontinence symptoms in women who sustain obstetric anal sphincter injuries and begin immediate vaginal electrical stimulation versus sham therapy. In this double-blind randomized controlled trial, women who sustained obstetric anal sphincter injuries were randomized to receive self-administered vaginal electrical stimulation using a commercial device or sham therapy with an identical device. Anal incontinence symptom severity was assessed at 1 week (baseline) and again at 13 weeks postpartum using the Fecal Incontinence Severity Index. The primary outcome was anal incontinence symptom severity measured by the total Fecal Incontinence Severity Index score at 13 weeks postpartum. Between February 2016 and September 2018, 48 women completed a 13-week follow-up. At 13 weeks postpartum, median Fecal Incontinence Severity Index scores were higher (more severe) in the vaginal electrical stimulation group (12; interquartile range, 0-23) than in the sham group (4; interquartile range, 0-10) (P = 0.04). Unlike the vaginal electrical stimulation group, the improvement in Fecal Incontinence Severity Index scores in the sham group (vaginal electrical stimulation: 12 [interquartile range, 8-22] to 12 [interquartile range, 0-23] [P = 0.12] vs sham: 12 [interquartile range, 6-18] to 4.0 [interquartile range, 0-11] [P < 0.001]) met the threshold for clinical significance based on the minimum important difference of the Fecal Incontinence Severity Index. At 13 weeks postpartum, women who underwent postpartum vaginal electrical stimulation reported more anal incontinence symptoms compared with those receiving sham therapy. Vaginal electrical stimulation after obstetric anal sphincter injury was not beneficial in reducing anal incontinence symptoms and may impede recovery.

Which factors are associated with anal incontinence after obstetric anal sphincter injury?

Obstetric anal sphincter injury (OASI) is an important factor in the etiology of anal incontinence. This study aimed to evaluate whether anal sphincter defects, levator avulsion or levator ballooning after OASI are associated with severity of anal incontinence. Furthermore, we evaluated whether factors such as constipation and altered stool consistency are associated with symptoms of incontinence after OASI. In this multicenter prospective observational cohort study, women with OASI were invited to participate at least 3 months after primary repair. All women completed validated questionnaires, including St Mark's incontinence score, Bristol stool scale (BSS) and Cleveland clinic constipation score (CCCS), and underwent four-dimensional (4D) transperineal ultrasound for assessment of the levator ani muscle and anal sphincter. In total, 220 women were included. Median follow-up was 4 months (range, 3-98 months). Univariate linear regression analysis showed an association of St Mark's incontinence score with a residual defect of the external anal sphincter (EAS) (β, 1.55 (95% CI, 0.04-3.07); P = 0.045), higher parity (β, 0.85 (95% CI, 0.02-1.67); P = 0.046), BSS (β, 1.28 (95% CI, 0.67-1.89); P < 0.001) and CCCS (β, 0.36 (95% CI, 0.18-0.54); P < 0.001). However, multivariate linear regression found an association of St Mark's incontinence score only with BSS (β, 1.50 (95% CI, 0.90-2.11); P < 0.001) and CCCS (β, 0.46 (95% CI, 0.29-0.63); P < 0.001). Residual defects of the EAS, detected on 4D transperineal ultrasound, are associated with severity of anal incontinence symptoms measured using St Mark's incontinence score 4 months after OASI repair. Furthermore, clinical factors such as constipation and altered stool consistency appear to influence this association and may therefore play a more important role in clinical management. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

A Retrospective Investigation on Electric Bidet Use as a Possible Cause of Anal Incontinence.

Objectives: The present study aimed to explore whether symptoms of anal incontinence (AI) in patients who used electric bidet toilets to clean the anus may improve after discontinuing bidet use. Methods: Fifty-three patients with AI who habitually used the bidets before or after defecation and were examined between June 2019 and September 2020 were included in this retrospective study. Questionnaires on Likert-scaled items that assessed bidet use were administered at baseline. The sum of all points was regarded as the “bidet use score”. The patients were instructed to discontinue bidets until subsequent examination. Incontinence severity was documented using the fecal incontinence severity index (FISI) score. Results: Follow-up data were available for 49 patients (92%). Of those, 43 had fecal incontinence and 6 had only mucus discharge at baseline. The median duration between the baseline and follow-up was 4 weeks. The median FISI score was significantly reduced at the follow-up [baseline vs. follow-up: 15 (range: 3-43) vs. 10 (range: 0-43); P < 0.0001]. The incidence of fecal incontinence was significantly lower at the follow-up than at the baseline (59% vs. 88%, P = 0.003). A higher maximum squeeze pressure and the absence of associated factors that may cause AI (such as rectoanal intussusception and/or rectocele, mucosal prolapse, and previous anorectal surgery) were significantly associated with a reduction of at least 50% in the FISI scores at follow-up; however, this was not observed for the bidet use score. Conclusions: Our findings suggest that electric bidet use is a possible cause of AI.

Do resistance exercises during biofeedback therapy enhance the anal sphincter and pelvic floor muscles in anal incontinence?

To determine if a biofeedback therapy that includes concentric resistance exercise for the anal sphincter muscles can improve muscle strength/function and improve AI symptoms compared to the traditional/non-resistance biofeedback therapy. Biofeedback therapy is the current gold standard treatment for patients with anal incontinence (AI). Lack of resistance exercise biofeedback programs is a limitation in current practice. Thirty-three women with AI (mean age 60years) were randomly assigned to concentric (resistance) or isometric (non-resistance) biofeedback training. Concentric training utilized the Functional Luminal Imaging Probe to provide progressive resistance exercises based on the patient's ability to collapse the anal canal lumen. Isometric training utilized a non-collapsible 10mm diameter probe. Both groups performed a biofeedback protocol once per week in the clinic for 12weeks and at home daily. High definition anal manometry was used to assess anal sphincter strength; symptoms were measured using FISI and UDI-6. 3D transperineal ultrasound imaging was used to assess the anal sphincter muscle integrity. Concentric and isometric groups improved FISI and UDI-6 scores to a similar degree. Both the concentric and isometric groups showed small improvement in the anal high-pressure zone; however, there was no difference between the two groups. Ultrasound image analysis revealed significant damage to the anal sphincter muscles in both patient groups. Concentric resistance biofeedback training did not improve the anal sphincter muscle function or AI symptoms beyond traditional biofeedback training. Anal sphincter muscle damage may be an important factor that limits the success of biofeedback training.

Anocutaneous advancement flap provides a quicker cure than fissurectomy in surgical treatment for chronic anal fissure\u2014a retrospective, observational study

PurposeAnocutaneous advancement flap is a surgical procedure for the treatment of chronic anal fissures. This study aimed to assess the results of anocutaneous advancement flap in a consecutive cohort of patients.MethodsThis is a retrospective, observational study. From 2000 to 2011, 481 patients had been operated for a single chronic anal fissure at the Maingau Clinic of the German Red Cross in Frankfurt am Main. The intention was to excise the fissure by fissurectomy (FIS) and then to cover the wound primarily with an anocutaneous advancement flap (AAF). The primary outcomes were resolution of symptoms and healing rates 1 month postoperatively. Secondary outcomes included incidences of early and late complications, postoperative incontinence, and recurrent fissure.ResultsAnocutaneous advancement flap was performed in 455 (94.6%). In 26 (5.4%) patients, AAF failed due to lacking skin and the wound left open after FIS. One month postoperatively, half of the patients with AAF were free of symptoms (53.2%) with complete wound healing (47.9%). The incidence of early complications within 1 month postoperatively was 0.9% after AAF. From 1 month to 5 years after operation anal abscesses and fistula occurred in 2.9%. Mild symptoms of anal incontinence were recorded in 0.2% and recurrent chronic anal fissure in 3.3% of patients. Subgroup analysis revealed improved wound healing 1 month postoperatively in patients with AAF compared to FIS.ConclusionAnocutaneous advancement flap is a very safe sphincter-sparing surgical option for CAF, provides a quicker cure than fissurectomy, and may be considered a good first-line surgical treatment option for chronic anal fissures if medical treatment failed.

Is pelvic floor muscle contractility an important factor in anal incontinence?

Pelvic floor muscle contractility (PFMC) may contribute to anal continence. The aim of this study was to assess the association between clinical and sonographic measures of PFMC and anal incontinence (AI) symptoms, after controlling for anal sphincter and levator ani muscle (LAM) trauma. This was a retrospective study of 1383 women assessed at a tertiary center between 2013 and 2016. All patients underwent an interview, including the StMark's incontinence score (SMIS) in those who reported AI symptoms, a clinical examination, including assessment of PFMC using the modified Oxford scale (MOS), and four-dimensional translabial ultrasound (TLUS). Sonographic measures of PFMC, i.e. cranioventral shift of the bladder neck (BN) and reduction of anteroposterior (AP) diameter of the levator hiatus, were measured offline using ultrasound volumes obtained at rest and on maximum pelvic floor contraction. The reviewer was blinded to all clinical data. Of the 1383 patients assessed during the study period, seven were excluded due to missing imaging data, leaving 1376 for analysis. Mean age of the participating women was 55 years and mean body mass index was 29 kg/m2 . AI was reported by 221 (16.1%) women, with a mean SMIS of 11.8. Mean MOS grade was 2.3. On TLUS, mean BN cranioventral shift was 5.9 mm and mean AP diameter reduction was 8.1 mm. LAM avulsion and significant external anal sphincter (EAS) defect were diagnosed in 24.8% and 8.7% patients, respectively. On univariate analysis, sonographic measures of PFMC were not associated with AI. Lower MOS grade was associated with symptoms of AI; however, statistical significance was lost on multivariate analysis. Clinical and sonographic measures of PFMC were not significantly associated with AI symptoms after controlling for EAS and LAM trauma. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Abstract PS9-26: Pelvic floor disorders and quality of life among breast cancer survivors

Abstract Introduction: Approximately 25% of women in the United States experience a symptomatic pelvic floor disorder such as urinary incontinence, pelvic organ prolapse, anal incontinence, and sexual dysfunction. Aspects associated with breast cancer treatment such a chemotherapy, oophorectomy/ovarian suppression, and endocrine therapy may predispose women to pelvic floor disorders. The prevalence of pelvic floor disorders among breast cancer survivors has been cited at 18%, but unpublished cross-sectional data suggests the prevalence may be much higher. In this study, 8.5% - 11.5% of participants experienced prolapse symptoms, 56.2% experienced anal incontinence symptoms, and 43.3% - 51.2% experience urinary incontinence symptoms. While pelvic floor dysfunction is associated with lower quality of life, it is unknown if breast cancer survivors with pelvic floor disorders experience decreased quality of life. The primary aim of this study was to assess if breast cancer survivors with pelvic floor disorders experience lower quality of life. Methods: Women 18 years or older who were previously treated for breast cancer and who were enrolled in a cancer research registry were invited to complete the Pelvic Floor Distress Inventory 20 (PFDI-20), the Female Sexual Function Index (FSFI), and the Short Form 12. Demographic and clinical data were abstracted from the research registry. A participant was considered eligible for the study if she had enrolled in the cancer registry and completed all core questions (i.e. demographics, cancer diagnosis, cancer treatment, endocrine therapy, medical/surgical history, and risk factors). As per standard PFDI-20 reporting, presence of a symptom was defined as answering a 1, 2, 3, or 4 to a question, while presence of a bothersome symptom was defined as answering a 2, 3, or 4. A score of 26 or less on the FSFI was considered indicative of sexual dysfunction. Results: A total of 634 women were considered eligible for enrollment in the study. 445 were able to be contacted, and 410 women agreed to participate in the study. Of those, 303 returned the PFDI-20 questionnaire and FSFI questionnaire, and 264 returned the SF-12 for response rates of 74% and 64%, respectively. Overall, higher scores on the PFDI-20 was associated with lower scores on both the physical and mental components of the SF-12 (Rho = -0.298, p = &amp;lt;.0001; Rho = -0.202, p = .0009, respectively). When the PFDI-20 was broken into subscores, higher POPDI scores (prolapse) was associated with lower physical component scores but not lower mental component scores. Higher CRADI scores (anal incontinence) and UDI-6 scores (urinary incontinence) were associated with lower physical and mental scores. Neither overall FSFI scores or subset domain scores were associated with lower physical or mental component scores of the SF-12. In linear regression analysis, PFDI summary score remained statistically significantly related to both mental and physical component subscores after controlling for age, race, stage of breast cancer, time since diagnosis, and use of adjuvant endocrine therapy. FSFI scores were related to age and endocrine therapy use, but were not related to SF-12 scores. Conclusion: Among a subset of breast cancer survivors, pelvic disorders including pelvic organ prolapse, urinary incontinence, and anal incontinence exist, and these disorders are associated with decreased mental wellbeing. All pelvic floor disorders except pelvic organ prolapse were associated with decreased physical wellbeing. None of the domains of female sexual dysfunction were associated with decreased physical or mental wellbeing among breast cancer survivors. A subset of breast cancer survivors experiences bothersome pelvic floor disorders and thus screening for these disorders can increase referrals to appropriate treatment and complement survivorship care to enhance overall quality of life. Citation Format: Jon F Pennycuff, Felice Yang, Tania Lobo, Caroline Jackman, Colleen McGuire, Ami Chitalia, Kristi Graves. Pelvic floor disorders and quality of life among breast cancer survivors [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS9-26.