Biofeedback bei Analinkontinenz

Biofeedback training is a well established method for the treatment of faecal incontinence. Prior to any biofeedback training program, a definitive diagnostic study is essential. Idiopathic faecal incontinence is the main indication for biofeedback training. Additional indications are a menacing faecal incontinence after deep anterior rectal excision with restoration of the rectal reservoir by an ileoanal pouch, anal sphincter reconstruction, rectopexy and rectocele repair. Only four studies provide evidence-based medical criteria. These, as well as numerous uncontrolled studies, show the effectiveness of biofeedback training for the treatment of faecal incontinence. Electrical stimulation of the anal sphincter is only shown to be effective in one controlled study in which it was combined with biofeedback training.     

Indicacion actual,técnica quirúrgica y resultados de la reparación anterior esfinteriana en el tratamiento de la incontinencia fecal

Faecal incontinence is a high prevalence disease in the general population. This pathology is commonly under-estimated and causes a great impact on clinical status and on the quality of life of affected patients. The prevalence of faecal incontinence in several studies has been estimated between 2% and 15% of the general population. The prevalence increases if we study selected populations, such as elderly people. The main cause of faecal incontinence is obstetric anal sphincter damage. In the past years, the presence of incontinence due to sphincter lesions, especially the obstetric ones, was an absolute indication of anterior anal sphincter repair. Actually, after knowing the long term follow up results of this technique, as well as the evolving knowledge on faecal incontinence and the development of new diagnostic and therapeutic techniques, this technique might be selected for cases with large sphincter defects. However there is limited information in the current literature on indications, surgical technique and results of anterior sphincter repair. The aim of this review is to analyse scientific evidence on current indications, surgical technique features and results of anterior sphincter repair as a therapy for faecal incontinence, also giving our point of view on controversial issues. A bibliography search was undertaken using Medline database including articles published from January 1985 to January 2009.     

Anal endosonography in the investigation of faecal incontinence

Forty-four consecutive patients with incontinence of solid stool of traumatic or idiopathic aetiology were examined by anal endosonography and standard anorectal physiology tests. Anal endosonography showed an external anal sphincter defect in four out of 11 (36 per cent) patients with idiopathic (neurogenic) incontinence. In the remaining seven patients both parts of the sphincter were intact and a linear relationship was found between the resting anal canal pressure and the endosonographic thickness of the internal anal sphincter. Twenty-eight out of 33 (85 per cent) patients with incontinence of traumatic origin had external sphincter defects, confirmed by concentric needle electromyogram mapping in the 19 patients in whom this was performed. Eleven of these 28 (39 per cent) patients also had disruption of the internal sphincter. Anal endosonography has revealed significant abnormalities in patients with faecal incontinence and has a complementary role to anorectal physiology in the routine investigation of these patients.     

Colorectal 25

Aims: To assess anal sphincter structure and functional outcomes following third-degree perineal tears and the effect of its disruption on the development of anal incontinence. Methods: Fifty-one consecutive patients, 41 primigravidae and 10 multigravidae, with third-degree intrapartum perineal tears, primarily repaired, were recruited 4 months postpartum. Patients completed questionnaires assessing faecal incontinence. Anal manometry and endosonography were then performed. Results: No patient reported incontinence prior to pregnancy. The incidence of faecal incontinence was 12 per cent. Six patients were incontinent of faeces and 10 incontinent of either flatus and/or fluid. Eighty-one per cent of anal incontinent patients were primigravidae (OR 0.96). Three women had previous third-degree tears, with one anal incontinence on subsequent delivery. Disruption of the external anal sphincter (EAS) was identified endosonographically in 26 patients. In 13 patients, there was an associated internal anal sphincter (IAS) defect. Clinically unsuspected tears of the Anal sphincter mechanism were diagnosed by anal endosonography in 46 per cent of asymptomatic patients. The EAS alone was involved in 14, IAS in three, and both in five patients. Clinical examination of women with anal incontinence identified an anal sphincter defect in 46 per cent. Ultrasound in anal incontinent patients showed an IAS defect in 42 per cent and an EAS defect in 52 per cent. All patients with faecal incontinence had a disruption of the EAS identified by endosonography (P < 0.05). No significant relationship was demonstrated between symptoms and anal manometry (P = 1.0, n.s.). Conclusions: Third-degree tears cause significant, although clinically unsuspected anal sphincter defects. It may be that anal manometry alone is not sufficient to exclude sphincter injury.     

Sphincter injury after anal dilatation demonstrated by anal endosonography.

Anal dilatation is still used in the treatment of anal fissure and haemorrhoids. Using anorectal physiology and anal endosonography we have studied 12 men presenting with faecal incontinence following anal dilatation. Resting anal pressures were low, pudendal nerve latencies were normal; 11 men had a disrupted internal anal sphincter and in ten this was extensively fragmented. Three also had defects of the external anal sphincter. These findings demonstrate for the first time the nature of the structural injury which may be caused by anal dilatation.     

Confirmation of endosonographic detection of external anal sphincter defects by simultaneous electromyographic mapping

Anal endosonography was performed in 13 consecutive patients with post-traumatic faecal incontinence. Thirteen acoustic defects in the external anal sphincter (two hyperechoic, four of mixed echogenicity and seven hypoechoic) were analysed electromyographically by locating under ultrasound guidance the tip of a concentric needle within the defect. The electromyographic activity in this zone was compared with ultrasonically normal muscle. Eleven of 13 sonographic defects showed no electrical activity on electromyography, there was one technical electromyography failure, and one defect was too deep to be reached by the electromyography needle. The electromyographic response was normal in each case within ultrasonically normal muscle. Anal endosonography is recommended as the initial investigation to locate defects, which may be confirmed electromyographically thereby limiting the number of painful needle insertions required for complete mapping of the external anal sphincter.     

Injured external anal sphincter in erectile dysfunction

The purpose of this study was to investigate the function of the bulbocavernosus muscle in patients with faecal incontinence as a result of injury to the external anal sphincter, and to find out whether faecal incontinence had any role in erectile dysfunction. The study comprised 16 men (age 41.6+/-6.8 years) whose erectile dysfunction and faecal incontinence followed an operation for anal fistula. Erection could not be maintained until ejaculation, which, if it did occur, was not in jets. Ten healthy volunteers acted as controls. The activity of the external anal sphincter and the bulbocavernosus muscle was recorded by electromyography; anal and penile bulb pressures were also recorded. Investigations showed that erectile function was normal. The external anal sphincter was repaired, and faecal control and erectile dysfunction were assessed. Patients were followed up for 19.6+/-3.2 months. The results showed that the bulbocavernosus reflex elicited no response in either the sphincter or the bulbocavernosus muscle. Their activity, recorded by electromyography, as well as anal and bulbar pressures at rest and on voluntary squeeze, and electrostimulation of the external anal sphincter, showed a significant reduction compared to the controls. Sphincteroplasty made the patients continent and restored erectile function and ejaculation to normal. We conclude from the current study that the reduced activity of the bulbocavernosus muscle is probably caused by injury to the external anal sphincter. It is suggested that erectile dysfunction is caused by the failure, during erection, of the contraction of the bulbocavernosus muscle to raise cavernosal pressure above systolic blood pressure. The loss of the rhythmical contractions of the bulbocavernosus muscle is probably why ejaculation did not occur in jets. Repair of the external anal sphincter provided a cure for faecal incontinence and erectile dysfunction. Anorectal disorders are believed to affect erectile function, a relationship that needs further investigation.     

肛管内超声对排粪失禁患儿肛门括约肌受损程度的评价

目的探讨肛管内超声对肛门内括约肌（IAS）、肛门外括约肌（EAS）及耻骨直肠肌（PR）形态及完整性的评估,从而为排粪失禁的原因及治疗方案的制订提供客观依据。方法回顾性分析2009年12月至2012年11月间山东大学第二医院收治的14例先天性肛门直肠畸形术后及4例先天性巨结肠术后排粪失禁患儿的临床资料。应用肛管内超声对IAS、EAS及PR进行观察,并进行括约肌受损程度评分;同时行肛管直肠测压评分和肛门功能评分,通过Spearman秩相关分析评价括约肌评分与肛管直肠测压评分和肛门功能评分之间的相关性。结果18例患儿中男13例,女5例,年龄10—16岁。肛门括约肌受损评分结果显示,括约肌轻度受损11例,中度受损65J,重度受损1例;另有PR受损4例。括约肌评分与肛管直肠测压评分之间呈正相关（P〈0．05）,而与肛门功能评分无明显相关性（P〉0．05）。结论肛管内超声可清楚显示IAS、EAS和PR的形态,明确其是否完整及受损程度,是评价肛门直肠畸形术后排粪失禁患儿非常有价值的方法,但并不能完全反映括约肌及肛门的功能状况。     

Anal sphincter defects. Correlation between endoanal ultrasound and surgery.

OBJECTIVE: This study was performed to (1) correlate and sphincter defects, identified by endoanal ultrasound with operative findings, and (2) define the appearance of such sphincter defects as seen at operation. SUMMARY BACKGROUND DATA: Endoanal ultrasonography is a minimally invasive method of imaging the anal sphincter complex and enables identification of anal sphincter defects. Little is known about the accuracy and limitations of endoanal ultrasound in identifying such defects. Furthermore, there are no data about the appearances of these endosonic sphincter defects as seen at operation. METHODS: Forty-four patients (40 women; age range, 26 to 80 years; mean age, 56 years) with fecal incontinence, undergoing pelvic floor repair, were investigated by endoanal ultrasound before operation. Endosonic findings were correlated with the appearances of external anal sphincter, internal anal sphincter, and intersphincteric space, at operation. Diagnosis of the site and type of defect was made by macroscopic appearances. Uncertainty about the type of sphincter defect was resolved by obtaining muscle biopsies for histology. RESULTS: All external sphincter defects seen by endoanal ultrasound (n = 23) were confirmed at operation. Twenty-one of 22 internal sphincter defects identified by endosonography also were confirmed at operation. In ten patients with a neuropathic anal sphincter complex, the morphology was normal on endosonography, and this was confirmed at operation. (Sensitivity and specificity of 100% for external anal sphincter; 100% and 95.5%, respectively, for internal and sphincter) CONCLUSIONS: These data show that endoanal ultrasound is an accurate method of identifying anal sphincter defects.     

Endocoil magnetic resonance imaging quantification of external anal sphincter atrophy.

BACKGROUND: Anal function depends on the integrity and quality of the sphincter muscles. The diagnosis of external anal sphincter atrophy on endocoil magnetic resonography has been associated with poor outcome from sphincter repair, although the imaging criteria for atrophy remain unclear. METHODS: Women with intact sphincters on endosonography and either normal (more than 60 cm H(2)O) (n = 9) or low (n = 16) squeeze pressures had endocoil magnetic resonography and electromyography. The area and fat content of the external anal sphincter and puborectalis were measured on mid-coronal magnetic resonography and images were graded as showing normal, intermediate or advanced atrophy. The definition of the external anal sphincter on endosonography and the thickness of the internal anal sphincter were also assessed. RESULTS: Women with a normal anal squeeze pressure had a larger external anal sphincter cross-sectional area (mean(s.d.) 240(56) versus 193(62) mm(2); P = 0.01) with a lower mean fat content (mean(s.d.) 23(4) versus 30(6) per cent; P < 0.001) than those with low squeeze pressures. There was an overall correlation between squeeze pressure, cross-sectional area (r = 0.32, P = 0.02) and fat content (r = - 0.51, P < 0.001). Patients with a thin (less than 2 mm) internal anal sphincter and/or a poorly defined external sphincter on endosonography were more likely to have atrophy (positive predictive value 74 per cent). CONCLUSION:: Potential endosonographic markers for external anal sphincter atrophy are suggested, and a visual scale for endocoil magnetic resonographic assessment has been validated.     

Endoanal ultrasound for detection of sphincter defects following childbirth

Introduction and hypothesis

The objectives of this study were to estimate the rates of sonographically detected anal sphincter defects within 72 h of childbirth and to evaluate intra- and interobserver agreement using three-dimensional (3-D) endoanal sonography data.

Methods

This is a prospective observational study of primiparous women delivered vaginally. Women without clinically identified anal sphincter lacerations underwent endoanal ultrasonography within 72 h of delivery. Intra- and interobserver agreement for diagnosis of sphincter defects using 3-D endoanal sonography data was calculated using kappa statistics.

Results

The rate of sphincter defects in 107 women undergoing 3-D endoanal sonography was 12 %. Characteristics of women with sonographically detected sphincter defects, compared to those without, included a significantly increased rate of clinically diagnosed second-degree lacerations (54 vs 20 %, p 0.008). The intra- and interobserver agreement for diagnosis of sphincter defects using 3-D endoanal sonography data was 0.82 [confidence interval (CI) 0.66–0.99] and 0.72 (CI 0.54–0.92), respectively.

Conclusions

Anal sphincter defects detected using endoanal sonography are common, occurring in 12 % of primiparous women, and are significantly associated with other less severe perineal lacerations. Overall and combining sonographically detected defects with clinically diagnosed lacerations, we estimate that 17.8 % of primiparous women delivered vaginally sustain anal sphincter injuries. The intraobserver agreement for diagnosis of sphincter defects is very good and the interobserver agreement is good.     

Intraobserver and interobserver agreement in anal endosonography

BACKGROUND: The aim of this study was to determine intraobserver and interobserver agreement for sonographic measurements of anal canal structures using anal endosonography (AES), and to determine interobserver agreement for the diagnosis of anal sphincter disruption. METHODS: Fifty-one consecutive patients referred for AES for the investigation of possible sphincter abnormality were examined. Studies were reviewed by two observers who measured anal canal structures at defined levels and locations, and recorded an opinion on sphincter integrity. Repeated measurements made by each observer were compared to determine intraobserver agreement, and measurements and diagnoses were compared between observers to determine interobserver agreement. RESULTS: Intraobserver agreement was better than interobserver agreement for measurements of anal canal structures. Interobserver limits of agreement for external sphincter measurements spanned 5 mm, whereas those for the internal sphincter spanned 1.5 mm. Interobserver agreement for diagnosis of sphincter disruption and internal sphincter echogenicity was very good (kappa = 0.80 and 0.74 respectively). CONCLUSION: The limits of agreement for intraobserver and interobserver measurements of anal canal structures on AES have been defined. Interobserver assessment of sphincter disruption is very good.     

Endosonography of the Anal Canal and Rectum

Endosonography has evolved into an effective tool for the accurate preoperative assessment of anorectal pathology, from idiopathic anal pain to malignancy. The published data suggest that endosonography is currently the best method for assessing the structural integrity of the anal sphincter and for staging rectal cancer. The development of new treatment modalities for rectal cancer, including local excision, preoperative radiotherapy, and total mesorectal excision, has increased the importance of accurate preoperative staging to allow the optimum treatment planning. However, there is little information about the impact of endosonographic findings on clinical decision making. Education, training, and quality control in the use of endosonography also require further work. This article aims to evaluate the usefulness and limitations of this technique in clinical practice.     

Meta-analysis to determine the incidence of obstetric anal sphincter damage

BACKGROUND: The reported incidence of anal sphincter injury after first (11.5-35.0 per cent) and subsequent (3.4-12.1 per cent) vaginal deliveries varies widely. In addition, the reported incidence of associated faecal incontinence ranges from zero to 68.2 per cent. The aim of this study was to perform a meta-analysis of reported incidences of postpartum anal sphincter defect diagnosed by endoanal ultrasonography (EAUS) and associated incidences of faecal incontinence. METHODS: A Medline search yielded five studies with more than 100 subjects who underwent EAUS after childbirth for evaluation of anal sphincter disruption and who were questioned about symptoms of faecal incontinence, defined as any impairment in flatus and stool control but not including urgency of defaecation. A Bayesian meta-analysis was performed to produce one inference while accounting for potential heterogeneity among the five study populations. RESULTS: Meta-analysis of 717 vaginal deliveries revealed a 26.9 per cent incidence of anal sphincter defect in primiparous women and an 8.5 per cent incidence of new sphincter defects in multiparous women. Overall, 29.7 per cent of anal sphincter defects were symptomatic. Some 3.4 per cent of women experienced postpartum faecal incontinence without an anal sphincter defect. In a Bayesian calculation, the probability of postpartum faecal incontinence due to a sphincter defect was 76.8-82.8 per cent. CONCLUSION:: The incidence of occult anal sphincter disruption following vaginal delivery is much higher than commonly estimated. However, at least two-thirds of occult defects are asymptomatic postpartum. The probability of faecal incontinence associated with an anal sphincter defect was 76.8-82.8 per cent.     

Imaging of anorectal disease

BACKGROUND: Over the past two decades developments in imaging have changed the assessment of patients with anorectal disease. METHODS: The literature on imaging techniques for anorectal diseases was reviewed over the period 1980-1999. RESULTS: For the staging of primary rectal tumours, phased array magnetic resonance imaging (MRI) may be regarded as the most appropriate single technique. The combination of endosonography or endoluminal MRI with ultrasonography or spiral computed tomography yields similar results. All techniques have limitations both for local staging and in the assessment of distant metastases. MRI or positron emission tomography is preferable for tumour recurrence. For perianal fistula, high-resolution MRI (phased array or endoluminal) is the technique of choice. For constipation, defaecography is the preferred technique, nowadays with emphasis on functional information. The role of magnetic resonance defaecography is currently being evaluated. For faecal incontinence, endosonography and endoluminal MRI give similar results in detecting sphincter defects; endoluminal MRI has the advantage of detecting external sphincter atrophy. CONCLUSION: High-resolution MRI, endosonography and defaecography are currently the optimal imaging techniques for anorectal disease.     

Faecal incontinence after seton treatment for anal fistulae with and without surgical division of internal anal sphincter: a systematic review

Objective The challenge of surgery for anal fistula is to eradicate the fistula track while maintaining anal continence. Seton placement is recommended to reduce postoperative faecal incontinence but interestingly a great range of functional impairment after surgery has been published. The aim of this study was to analyse the influence of intra‐operative internal anal sphincter division during tight or cutting seton technique for cryptogenic anal fistula, on the results of recurrence and postoperative faecal incontinence. Method A systematic literature review was performed to identify published series from 1966 to May 2007 of patients with anal fistula treated by a tight or cutting seton technique. The published series has been divided in to those where preservation of internal anal sphincter was performed (PIAS group) or where intra‐operative surgical division was undertaken in the time of seton placement (SIAS group) .The main endpoints of the review were to study anal fistula recurrence rate and postoperative faecal incontinence. Results Eighteen studies including 19 series and 448 patients were analysed in detail. Recurrence rate was 5.0% and 3.0% in PIAS and SIAS group respectively. Overall faecal incontinence rate was 5.6% in PIAS group and 25.2% in SIAS group. Conclusion Although based on low‐evidence studies, intra‐operative preservation of internal anal sphincter at the time of seton insertion for anal fistula seems to reduce the postoperative faecal incontinence without a substantial increase in recurrence rates.     

Anal endosonographic findings in the follow-up of primarily sutured sphincteric ruptures.

Twenty-four women with primary suture of an obstetric tear of the anal sphincter were examined with anal endosonography a median of 12 (range 3-18) months after delivery. Endosonography was normal in ten patients, of whom one was incontinent. The examination showed a defect in the external anal sphincter in 13 patients; six of these were incontinent, two of whom had normal findings on palpation. An isolated internal sphincter defect was found in a continent patient. Since anal endosonography causes no more discomfort than digital examination, it may be useful to identify patients who would benefit from surgical reconstruction of the anal sphincter.     

Three-dimensional endoanal sonography in assessing anal canal injury

BACKGROUND: Instrument design limits endosonography of the anal canal to the axial plane, with no capability for longitudinal imaging or measurement. Using three-dimensional reconstructions, the relationship between the radial and linear extent of an anal sphincter tear has been explored, and sex differences in anal canal and sphincter length have been established. METHODS: Three-dimensional reconstructions were performed in 20 controls and 24 patients with faecal incontinence found to have 25 external and five internal sphincter defects. The radial and linear extent of any sphincter tear was measured. In controls the length of the sphincters was compared with the total anal canal length, and the maximum and mean internal sphincter thickness was compared. RESULTS: The radial angle of an internal or external sphincter defect was significantly related to its length (R2 = 96.8 per cent and R2 = 84.4 per cent respectively; both P < 0.001). The anal canal was longer in men than in women (mean(s.d.) 32.6(5.3) versus 25.1(3.4) mm; P < 0.001). The internal anal sphincter was also longer in men (25.6(6.3) versus 19.8(4.0) mm; P < 0.02), but the mean internal sphincter length as a percentage of total anal canal length did not differ (78.3 versus 78.7 per cent; P not significant). The anterior external anal sphincter was longer in men than in women (32.6(5.3) versus 15.3(2.8) mm; P < 0.001), and formed a greater percentage of total anal canal length (100 versus 62.9 per cent; P < 0.001). CONCLUSION: Multiplanar imaging has revealed a direct relationship between the length of a sphincter tear and its radial extent as shown on axial scanning. Marked sex differences in sphincter configuration have been demonstrated. In women the shorter anterior sphincter length highlights the risk of complete sphincter disruption with extensive tears.     

The effect of vaginal delivery on anal function

The commonest cause of faecal incontinence is considered to be childbirth. In this review we consider the available data on the prevalence of faecal incontinence in the community and the incidence of incontinence after childbirth. The results and implications of studies on childbirth using anal manometry, neurophysiological tests and anal ultrasound are discussed. The development of symptoms are more likely with a third degree tear and forceps delivery. Reduced resting and squeeze pressures are seen early after vaginal delivery with recovery noted with time. Reduced pressures have been seen in symptomatic and asymptomatic women and there is no correlation of the pressures with the presence or absence of a sphincter defect or evidence of pudendal neuropathy. Anal manometry can not be used as an indication of muscle or nerve injury. Both sphincter defects and evidence of pudendal neuropathy are common after vaginal delivery but these are not necessarily associated with symptoms. It is suggested that such occult sphincter injuries may go on to be symptomatic in later life. The number of these injuries, however, is far greater than the documented prevalence of incontinence in the community, and hence many must remain asymptomatic. Their true clinical significance remains uncertain.     

The anatomical basis of anal endosonography

Purpose: Anal endosonography is an imaging modality new to the diagnostic workup of incontinence. Interpretations even of normal endosonomorphologic findings now vary considerably. The conjoined longitudinal muscle (LM), a widely ignored structure, has until recently not been fully recognized by anal endosonography. The aim of this study, therefore, was to accurately determine the normal anatomy of the anal canal and correlate it with the findings obtained by anal endosonography. Methods: Eight postmortem specimens of the anal canal were examined by endosonography. The findings were correlated with macroscopical dissection and gross sectional histology of the same specimens. Results: The external echogenic ring is composed of two anatomical structures: the LM and the external anal sphincter (EAS). However, during anal endosonography the LM cannot always be differentiated from the EAS. Histologically, the relation of the diameters of the LM and the EAS ranged from 0.45:1 to 1.25:1. The narrow hyperechogenic ring between the inner hypoechoic layer and the external hyperechoic ring is an artificial finding that cannot be related to a distinct anatomical structure and most likely represents a sonographic interface. Conclusions: This study exactly outlines the relation of diameters of the conjoined longitudinal muscle and external anal sphincter for the first time. Until now, the LM has been underestimated in its dimensions. The role of such a thick muscular structure should be included in the conception of anal continence in the future. Especially in view of the fact that anal endosonography is increasingly used in the diagnostic workup of incontinence and fistula in ano, it is essential to understand the anatomical basis of endosonography. This study accurately delineates the sonomorphology of the anal muscles. When viewed in light findings reported here, endosonographic findings in diseases of the anal canal are now based on a correct idea of the correlation between endosonomorphology and anal anatomy. Received: 28 January 1997/Accepted: 28 February 1997