Combined anorectal manometry and defecography in 50 consecutive adults with fecal incontinence

Fifty consecutive patients presenting with fecal incontinence were evaluated prospectively with anorectal manometry, defecography, and other tests of anorectal function to assess the clinical utility of defecography in fecal incontinence. Leakage of contrast at rest and failure to narrow the anorectal angle with pelvic squeezing were specific but not sensitive predictors of decreased sphincter pressures as determined by manometry. Thus, after manometry, defecography provided no additional information regarding sphincter strength. Retention of contrast in large rectoceles or incomplete rectal evacuation at defecography had excellent correlation with the presence of clinical symptoms of outlet obstruction constipation (present concurrently with incontinence) and indicated an etiology of outlet obstruction symptoms. Defecography may provide useful information in incontinent patients with outlet obstruction constipation symptoms but has little additive value to anorectal manometry in incontinent patients without such symptoms.     

Anorectal manovolumetry in the diagnosis of fecal incontinence

PURPOSE: This study was designed to investigate rectal reservoir function and anal pressures in patients with fecal incontinence using anorectal manovolumetry and to evaluate the reproducibility of the investigation. METHODS: Forty-eight patients with fecal incontinence were investigated with respect to anal pressures and rectal volume changes and sensibility in response to stepwise increased rectal pressures (5–60 cm of H2O). Patients with known rectal wall diseases were excluded. Results were compared with those of 25 control subjects investigated in a similar manner. In ten individuals in the latter group, investigation was repeated after 5 minutes and 24 hours. RESULTS: Resting pressure (RP), squeezing pressure (SP), and the difference between SP and RP was lower in patients than in controls (P <0.0001). There was no significant difference between patients and controls concerning rectal sensibility or compliance (P >0.05), but there was a correlation between RP and rectal compliance (r =0.25;P <0.05) and between SP and rectal compliance (r =0.30;P <0.01). There was good reproducibility of RP and SP after five minutes (r=0.88–0.92;P <0.001). The day-to-day variation was larger for RP (r=0.52;P >0.05) compared with SP (r=0.89;P <0.001). Rectal compliance at 40 cm of H2O was reproducible after 5 minutes (r=0.98;P<0.0001) and 24 hours (r=0.88;P<0.01). CONCLUSIONS: These results indicate that the primary defect in incontinent patients is a sphincter dysfunction. Any reduction in rectal compliance is likely to be a secondary phenomenon.Read at the XVth Biennial Congress of the International Society of University Colon and Rectal Surgeons, Singapore, July 2 to 6, 1994.     

Anorectal functioning in fecal incontinence

Manometric testing was performed on three groups of subjects: 14 patients complaining of fecal incontinence, 14 age- and sex-matched continent patients, and 14 sex-matched younger normal controls. The younger group displayed significantly stronger contractions of the external anal sphincter and puborectalis than the two patient groups, which did not differ. No differences were found in the relaxation of the internal anal sphincter. The incontinent group required a significantly larger stimulus in order to detect rectal distension compared to either the continent patients or the younger normals. An additional group of unmatched normals and incontinent patients demonstrated significant differences in their ability to retain rectally infused saline. The patients leaked sooner and retained less;however, the performance of the normals was considerably reduced from that reported in previous studies. The aging process seems to result in weakening of the striated muscles of the anal canal, although fecal incontinence need not occur. The afferent limb of the anorectal sensorimotor mechanism does not necessarily deteriorate with aging. A lower threshold for sensation of rectal distension among continent individuals apparently helps them to avoid incontinent episodes, even though maximum contractile pressures in their anal canal are no different from a comparable group of incontinent individuals.     

Measurement of the anorectal angle by defecography for the diagnosis of fecal incontinence

We assessed the reliability of anorectal angle (ARA) measurement as an index of fecal incontinence. The “posterior” ARA was measured at rest, squeezing, and straining in 69 continent and 82 incontinent subjects all complaining of various evacuation dysfunctions. The two groups were homogeneous with regard to sex distribution (48.6% vs. 51.4% men and 44.7% vs. 55.3% women, n.s.) and age (56.5±10.2 vs. 59.3±9.7 years, n.s.). The incidence of rectal prolapse was the same in the two groups (40 each). The intraobserver agreement index from two independent measurements (Pearson's correlation coefficient), age, and gender interaction [T ² Hotelling test in multivariate analysis of variance (ANOVA)] and the most discriminating category of ARA measurement (Fisher's F test in ANOVA) were calculated. In addition, the relationship between ARA and severity of incontinence was assessed by the eta coefficient. Pearson's correlation coefficient was between 0.78 and 0.98 (P<0.01). The mean ARA differed significantly between the continent and incontinent subjects (104.5±10.3° vs. 116.2±23.6° at rest, 84.5±14.2° vs. 95.1±20.1° on squeezing, and 133.7±21.7° vs. 141.7 ± 25.9° on straining; T ² 0.066, P<0.05 in multivariate ANOVA). No interaction was noted between groups and gender (T ² = 0.023; F = 1.11, n.s.). Resting ARA was shown by ANOVA to be the most discriminating index (F = 9.4 P<0.01) between the two groups. Overall, ARA measurement was correlated with the severity of fecal incontinence (eta coefficient: 0.894 at rest; 0.811 on squeezing; 0.695 on straining); its accuracy was 79%, the false-positive rate was 15.3% and the false-negative rate 26.5%. Irrespective of the underlying abnormality, namely rectal prolapse, ARA measurement by defecography can: (a) be reinterpreted reliably by the same observer and (b) differentiate continent from incontinent subjects. Accepted: 25 February 1999     

Transanal ultrasound and manometry in the evaluation of fecal incontinence

PURPOSE: This preliminary study was undertaken to clarify the role of ultrasonography of anal sphincters in the colorectal laboratory. METHODS: Twenty-eight parous female patients with fecal incontinence were evaluated with transanal ultrasonography (TAUS), anal manometry, and pudendal nerve terminal motor latency (PNTML). Ultrasound images were recorded and labeled in centimeters from the anal verge. The continuity of the internal anal sphincter (IAS) was identified as either intact or disrupted. The separation of the external anal sphincter (EAS) was measured at the 1.5-cm level and below. TAUS findings were then compared with anal manometric pressures. Clinical data were obtained by patient interview and examination during TAUS. RESULTS: Evidence of IAS disruption was associated with significantly decreased mean maximum resting pressures (P=0.023). EAS separation was inversely proportional to mean maximum squeezing pressures (r=?0.61). In the group of patients offered sphincteroplasty, the IAS was disrupted more often (P=0.016), mean maximum resting pressures were significantly lower (P=0.023), mean EAS separation was significantly greater (P=0.022), and mean PNTML was significantly faster (P=0.004). Twenty-five percent of patients with normal clinical examinations had significant muscular injury by TAUS requiring sphincteroplasty. CONCLUSIONS: Manometric findings correlate significantly with anal sphincter defects visualized by TAUS. TAUS is useful in the evaluation and management of patients with fecal incontinence.     

Anorectal pressure gradient and rectal compliance in fecal incontinence

To study whether anorectal pressure gradients discriminated better than standard anal manometry between patients with fecal incontinence and subjects with normal anal function, anorectal pressure gradients were measured during rectal compliance measurements in 36 patients with fecal incontinence and in 22 control subjects. Anal and rectal pressures were measured simultaneously during the rectal compliance measurements. With standard anal manometry, 75% of patients with fecal incontinence had maximal resting pressure within the normal range, and 39% had maximum squeeze pressure within the normal range. Anorectal pressure gradients did not discriminate better between fecal incontinence and normal anal function, since, depending on the parameters used, 61%–100% of the incontinent patients had anorectal pressure gradients within the normal range. Patients with fecal incontinence had lower rectal volumes than controls at constant defecation urge (median 138 ml and 181 ml, P<0.05) and at maximal tolerable volume (median 185 ml and 217 ml, P<0.05). We conclude that measurements of anorectal pressure gradients offer no advantage over standard anal manometry when comparing patients with fecal incontinence to controls. Patients with fecal incontinence have a lower rectal volume tolerability than control subjects with normal anal function. Accepted: 5 June 1998     

Accuracy of anorectal manometry in patients with fecal incontinence

Background/Aim: Patients with fecal incontinence (FI) have lower anal resting (MRP) and squeeze (MSP) pressure and an impaired sensitivity compared to healthy people. However, whether anorectal manometry (ARM) can separate precisely between health and disease is discussed controversially. The aim was to evaluate the accuracy of ARM in a huge cohort of patients and controls. Methods: ARM was obtained in 144 controls and in 559 FI patients. MRP, MSP, and balloon volume at first perception (BVP) and urge sensation (BVU) were determined. Receiver operating curve analysis was used to determine optimal cut-offs and sensitivity, specificity and accuracy calculated. Results: FI patients showed lower MRP, MSP, BVU (p < 0.001) and a higher BVP (p = 0.007). Deterioration of the ARM parameter increased with FI severity. ARM demonstrated an excellent sensitivity (91.4%) and accuracy (85.8%), but only a moderate specificity (62.5%). The sensitivity of ARM rose with FI severity. The pressure data showed higher sensitivity and accuracy than the sensory data despite comparable specificity. Conclusions: Sensitivity and accuracy of single ARM parameters is only moderate for the pressure data and poor for the sensory data. In contrast, ARM demonstrated an excellent sensitivity, a moderate specificity, and a convincing accuracy justifying its use in clinical routine.     

Anorectal manometry in the diagnosis of paradoxical puborectalis syndrome

This prospective study was undertaken to compare the utility of anorectal manometry (ARM) with that of anal electromyography (EMG) and cinedefecography (CD) in the diagnosis of paradoxical puborectalis syndrome (PPS). One hundred sixteen consecutive patients with a history of chronic constipation were prospectively assessed. These 35 males and 81 females were of a mean age of 60 years, ranging from 18 to 84 years. The incidences of PPS were 63 percent for ARM, 38 percent for EMG, and 36 percent for CD. The correlations of PPS were suboptimal: ARM and EMG, 70 percent; and ARM and CD, 61 percent. A two-tiered system for the manometric classification of PPS was developed. First, the evacuation pressure curve pattern was classified as a normal relaxed downward (Type A; n=43), a nonrelaxed flat or equivocal (Type B; n=36), and a paradoxical upward (Type C; n=37). PPS was noted with increasing incidence within curve types (21 percent in Type A, 64 percent in Type B, and 95 percent in Type C). Second, an evacuation index (EI = evacuation pressure/squeeze pressure) was defined: Group I (El<0; n=43), Group II (0EI<0.25; n=24), Group III (0.25EI<0.5; n=27), and Group IV (EI0.5; n=18). The finding of PPS also correlated with the EI group: 21 percent in Group I, 67 percent in Group II, 74 percent in Group III, and 100 percent in Group IV. This subdivision of curve types and EI groups may provide a role in the diagnosis of PPS.Dr. Ger was a visiting colorectal surgeon from the Section of Colon and Rectal Surgery, Department of Surgery, National Defense Medical Centre and Tri-Service General Hospital, Taipei, Taiwan, R.O.C.     

Dynamic anal manometry: physiological variations and pathophysiological findings in fecal incontinence.

A recently developed technique for dynamic anal manometry was used to study 40 healthy volunteers and 23 patients with fecal incontinence. Seven parameters of anal function were measured. Intraindividual variation of the parameters was studied in 5 females and 5 males. The results of dynamic anal manometry were compared with standard pull-through static anal manometry and correlated well. During opening of the anal sphincter at rest, compliance increased with increasing distension. Males had higher maximal closing pressures during squeeze and lower anal compliance during squeeze than females. There was no sex differences of the sphincter measurements at rest. Age had little effect, and gender had no effect on the measurements. With standard anal manometry, 6 of 23 patients with fecal incontinence both had maximal resting pressure and maximal squeeze pressure within the normal range. When dynamic anal manometry was used, all 23 patients showed one or more abnormal values. The method of dynamic anal manometry provides an opportunity for a more thorough assessment of anal sphincter function than previous manometric methods.     

Clinical value of anorectal manometry index in neurogenic fecal incontinence

PURPOSE: The present communication is an endeavor to assess the value of a simple motility index to separate patients with neurogenic or idiopathic fecal incontinence from those patients with the secondary form of the disease. METHODS: Study population consisted of 23 patients with idiopathic fecal incontinence and 13 patients with fecal incontinence secondary to surgical or obstetric trauma. They all had a standard anorectal manometric study after a 12-hour fast. A motility index was then prepared taking into consideration the peak sphincter pressure values, contractility endurance, and rectal sensory threshold. RESULTS: Despite differences in the mean peak squeeze pressure and sensory threshold between the two groups, there were significant overlaps for all parameters of standard anorectal manometry in both groups. However, patients with idiopathic incontinence had an index of smaller than 28, and the group with the secondary form of incontinence had indexes higher than 30. CONCLUSIONS: 1) None of the four parameters of a conventional anorectal manometry can accurately separate patients with neurogenic incontinence from those with secondary forms of the disorder. 2) The anorectal motility index presented here can accurately separate the two groups. 3) This index is superior to the standard anorectal manometry in evaluating patients with fecal incontinence.     

Delayed rectal sensation with fecal incontinence. Successful treatment using anorectal manometry

Retraining of the external sphincter response to rectal distention and improving the sensory threshold to balloon distention is documented as effective treatment for fecal incontinence in selected patients. Using anorectal manometric techniques, delayed conscious rectal sensation was demonstrated in 28% of 46 consecutive patients referred for fecal incontinence. In patients with delayed recognition of balloon distention, conscious rectal sensation seemed to correlate with a consistent level of internal sphincter relaxation rather than the primary stimulus of balloon distention of the rectum. Anorectal retraining techniques resulted in correction of sensory delay of 2-22 s, elimination of fecal incontinence, and improved sensory threshold in 10 of 13 patients. This previously unreported sensory abnormality represents a treatable manometric abnormality identified by anorectal motility in patients with fecal incontinence.     

Clinical, anorectal manometry and surface electromyography in the study of patients with fecal incontinence.

OBJECTIVE: to demonstrate the role of the clinical, anorectal manometry and surface electromyography in the assessment of patients with fecal incontinence. PATIENTS AND METHODS: ninety-three patients with fecal incontinence are retrospectively reviewed and the data obtained from the directed clinical history, physical examination of the anal region, digital rectal examination, anorectal manometry and surface electromyography are analyzed. A treatment was administered in accordance with the alterations encountered and the results evaluated at 3 and 12 months. RESULTS: fecal incontinence was predominant (91.4%) in women age 59.7+/-11. A background of obstetric risks (48.2%) was frequent in women. Also, 73.1% of the patients presented diarrhea. The anorectal manometry (ARM) demonstrated some alterations in 90.3% of the patients, whereas a hypotonic sphincter was the most common finding (85.7%). Rectal sensitivity or distensibility alterations were present in the rest of the patients. In 79.2% ofthe cases, hypotonic sphincter was associated with rectal sensitivity or distensibility alterations. In 65.2% of patients with hypotonic external anal sphincter, damage of the pudendal nerve was found and therefore biofeedback was indicated in 41.9% of them. CONCLUSIONS: the clinical study of the patients, together with the anorectal manometry and surface electromyography enables the identification of the cause of FI and its treatment. These studies demonstrate that in most cases the origin of the incontinence is due to multiple etiologies, however the treatment of some of the factors involved frequently improves the symptomatology.     

Anorectal sensory and motor function in neurogenic fecal incontinence. Comparison between multiple sclerosis and diabetes mellitus

We measured anorectal sensory and motor function in 11 patients with multiple sclerosis and fecal incontinence, 11 continent patients with multiple sclerosis, 10 diabetics with fecal incontinence, and 12 healthy control subjects. The threshold volume at which patients with multiple sclerosis and fecal incontinence experienced rectal sensation was higher than that in healthy controls (42.7 +/- 6.2 mL vs. 13.3 +/- 2.8 mL; P less than 0.01) and was similar to that in incontinent diabetics (36.5 +/- 5.7 mL). Patients with multiple sclerosis and incontinent diabetics also showed increased thresholds of phasic external sphincter contraction compared with controls (P less than 0.05). Diabetics with incontinence had reduced resting and maximal voluntary anal sphincter pressures compared with controls (P less than 0.05), whereas patients with multiple sclerosis and incontinence showed only decreased maximal voluntary anal sphincter pressures (P less than 0.01 vs. controls and diabetics). Incontinent patients with multiple sclerosis also required smaller volumes of rectal distention to inhibit internal sphincter tone compared with diabetics and controls (P less than 0.01). Decreased maximal voluntary squeeze pressures were less severe in continent patients with multiple sclerosis than in incontinent patients with multiple sclerosis. We conclude that impaired function of the external anal sphincter and decreased volumes of rectal distention to inhibit the internal anal sphincter or both may contribute to fecal incontinence in multiple sclerosis. In addition, increased thresholds of conscious rectal sensation in some incontinent patients with multiple sclerosis and diabetes mellitus may contribute to fecal incontinence by impairing the recognition of impending defecation.     

Rational neurologic diagnosis in fecal incontinence]

The effective therapy of a disturbance of anal continence requires an adequate preoperative diagnostics. In most cases this includes some kind of neurophysiological investigation. Close cooperation between the internist, the surgeon and the neurologist is advantageous. The initial history, clinical examination and electromyography of the pelvic floor will usually be enough to differentiate between aetiologies. In the first phase it is necessary to decide whether the problem is neurogenic or muscular, and then to see localising signs for a nerve defect (central or peripheral) or, respectively, signs of a defect in the skeletal musculature. It must be said that a peripheral nerve lesion (eg. a stretching injury of branches of the pudendal nerve) and a muscular defect may be combined. At the end of the diagnostic process the surgeon or internist and neurologist must decide together whether the diagnosis is appropriate, and then whether an operative or non-operative approach to treatment is fitting. In the second phase of diagnosis are further neurophysiological investigations, which are only indicated in more special circumstances. These investigations include: nerve conduction velocities, reflex latencies (anal-, bulbocavernosus-, and pudendoanal reflexes), evoked potentials, and the single fibre EMG to determine fibre density. These neurophysiological investigation in proctology allows the clinician a wider scope of diagnostic possibilities, which should lead to more sensible therapeutic options being taken.     

Vectormanometry for differential diagnosis of fecal incontinence

PURPOSE: This study was designed to investigate the reliability of three-dimensional vectormanometry for differential diagnosis of fecal incontinence. METHODS: Eight-channel, continuous pull-out perfusion manometry was performed on 23 female patients with traumatic (n=11) or idiopathic (n=12) incontinence, respectively. RESULTS: At rest, the minimum sector pressure of patients with traumatic incontinence (32±14 mmHg) was significantly lower than it was in the controls (76±16 mmHg) and in those with idiopathic incontinence (64±28 mmHg) (P<0.001). At maximum squeezing, the minimum sector pressure was 57±22 mmHg in patients with traumatic incontinence and 79±33 mmHg in those with idiopathic incontinence, both being significantly lower than in the control group with 152±27 mmHg (P<0.001). The asymmetry index of the patients with a sphincter defect was significantly higher, both at rest (23±13 percent) and squeeze (26±12 percent), in comparison with the control group (7 ±2 percent at rest and 6.2±1.6 percent at squeeze) and the patients with idiopathic incontinence (10±5 percent at rest and 8.4±4 percent at squeeze). CONCLUSION: Three-dimensional vectormanometry identifies localized pressure deficits in the anal canal, thereby differentiating between sectorial and global sphincter insufficiency.     

Role of manometry, defecography and anal endosonography in the evaluation of colorectal disorders.

OBJECTIVE: altered motility or anatomy of the rectum, anus and perineal floor may lead to symptoms which are unresponsive to routine therapeutic approaches. These disturbances usually lead to constipation, fecal incontinence, or both. Different tests and techniques for evaluating anorectal and perineal disorders, developed in the last two decades, make a better understanding of these disorders possible. This study was designed to evaluate the diagnostic benefits of combining manometry, defecography and anal endosonography in the assessment of patients with anorectal disorders. METHODS: twenty-five children with constipation (with or without soiling), incontinence and/or prolapse underwent anal manometry, defecography and anal endosonography. Group A consisted of 9 children with fecal incontinence, group B consisted of 10 children with constipation with soiling, and group C comprised 6 children with constipation without soiling. RESULTS: in group A resting incontinence was associated with a hypotonic external sphincter in 4 out of 9 patients, 2 of whom had internal anal sphincter thinning. In group B resting incontinence was associated with a hypotonic external sphincter in 8 out of 10 patients, 6 of whom had internal anal sphincter thinning. In group C these associations were not seen in any of the patients. CONCLUSIONS: barium enema is not sufficient for an accurate diagnosis of anorectal disorders. No single test is capable of revealing the type of disease. Anal manometry, defecography and endosonography are complementary procedures in the assessment of this group of disorders. This new approach will improve our knowledge of the pathogenesis of these disorders in children. However, further studies are needed to obtain conclusive evidence.