Rectal Volume Tolerability and Anal Pressures in Patients With Fecal Incontinence Treated With Sacral Nerve Stimulation

Purpose Sacral nerve stimulation has proven to be a promising treatment for fecal incontinence when conventional treatment modalities have failed. There have been several hypotheses concerning the mode of action of sacral nerve stimulation, but the mechanism is still unclear. This study was designed to evaluate the results of rectal volume tolerability, rectal pressure-volume curves, and anal pressures before and six months after permanent sacral nerve stimulation and to investigate the mode of action of sacral nerve stimulation. Methods Twenty-nine patients with incontinence (male/female ratio = 6/23; median age, 58 (range, 29–79) years) underwent implantation of a permanent sacral electrode and neurostimulator after a positive percutaneous nerve evaluation test. Wexner incontinence score, rectal distention with thresholds for “first sensation,” “desire to defecate,” and “maximal tolerable volume,” rectal pressure-volume curves, anal resting pressure, and maximum squeeze pressure were evaluated at baseline and at six months follow-up. Results Median Wexner incontinence score decreased from 16 (range, 6–20) to 4 (range, 0–12; P < 0. 0001). Median “first sensation” increased from 43 (range, 16–230) ml to 62 (range, 4–186) ml (P = 0.1), median “desire to defecate” from 70 (range, 30–443) ml to 98 (range, 30–327) ml (P = 0.011), and median “maximal tolerable volume” from 130 (range, 68–667) ml to 166 (range, 74–578) ml (P = 0.031). Rectal pressure-volume curves showed a significant increase in rectal capacity (P < 0.0001). The anal resting pressure increased significantly from 31 (range, 0–109) cm H₂O to 38 (range, 0–111) cm H₂O (P = 0.045). No significant increase in maximum squeeze pressure was observed. Conclusions For patients with fecal incontinence successfully treated with sacral nerve stimulation, there was a significant increase in rectal volume tolerability and rectal capacity. A significant increase in anal resting pressure, but not in maximum squeeze pressure, was found. We suggest that sacral nerve stimulation causes neuromodulation at spinal level. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

The relationship of pudendal nerve terminal motor latency to squeeze pressure in patients with idiopathic fecal incontinence

PURPOSE: With the advent of transanal ultrasonography it has been possible to identify those incontinent patients without sphincter defects. The majority of these patients are now thought to have neurogenic fecal incontinence secondary to pudendal neuropathy. They have been found to have reduced anal sphincter pressures and increased pudendal nerve terminal motor latencies. The aim of this study was to determine whether in those incontinent patients who do not have a sphincter defect, prolonged pudendal nerve terminal motor latency correlates with anal manometry, in particular maximum squeeze pressure. METHODS: Sixty-six incontinent patients were studied with transanal ultrasonography, anorectal manometry, and pudendal nerve terminal motor latency. Twenty-seven continent controls had anorectal manometry and pudendal nerve terminal motor latency measured. RESULTS: Maximum resting pressure and maximum squeeze pressure were significantly lower in the group of incontinent patients with bilateral prolonged pudendal nerve terminal motor latency (median maximum resting pressure = 26.5 mmHg; median maximum squeeze pressure = 60 mmHg) when compared with incontinent patients with normal bilateral pudendal nerve terminal motor latencies (median maximum resting pressure = 46 mmHg; median maximum squeeze pressure = 79 mmHg; maximum resting pressure P = 0.004; and maximum squeeze pressure P = 0.04). In incontinent patients with no sphincter defects no correlation between pudendal nerve terminal motor latency and maximum squeeze pressure was found (r = -0.109, P = 0.48) and maximum squeeze pressure did not correlate with bilateral or unilateral prolonged pudendal nerve terminal motor latency (r = -0.148, P = 0.56 and r = 0.355, P = 0.19 respectively). CONCLUSIONS: In patients with idiopathic fecal incontinence damage to the pelvic floor is more complex than damage to the pudendal nerve alone. Although increased pudendal nerve terminal motor latency may indicate that neuropathy is present, in patients with neuropathic fecal incontinence, pudendal nerve terminal motor latency does not correlate with maximum squeeze pressure. Normal pudendal nerve terminal motor latency does not exclude weakness of the pelvic floor.     

Preoperative Anal Manometry Predicts Continence After Perineal Proctectomy for Rectal Prolapse

Purpose This study examines whether preoperative anal manometry and pudendal nerve terminal motor latency predict functional outcome after perineal proctectomy for rectal prolapse. Methods All adult patients treated by perineal proctectomy for rectal prolapse from 1995 to 2004 were identified (N = 106). Forty-five patients underwent anal manometry and pudendal nerve terminal motor latency testing before proctectomy and they form the basis for this study. Results Perineal proctectomy with levatoroplasty (anterior 88.9 percent; posterior 75.6 percent) was performed in all patients, with a mean resection length of 10.4 cm. Four patients (8.9 percent) developed recurrent prolapse during a 44-month mean follow-up. Preoperative resting and maximal squeeze pressures were 34.2 ± 18.3 and 60.4 ± 30.5 mmHg, respectively. Pudendal nerve terminal motor latency testing was prolonged or undetectable in 55.6 percent of patients. Grade 2 or 3 fecal incontinence was reported by 77.8 percent of patients before surgery, and one-third had obstructed defecation. The overall prevalence of incontinence (77.8 vs. 35.6 percent, P < 0.0001) and constipation (33.3 vs. 6.7 percent, P = 0.003) decreased significantly after proctectomy. Patients with preoperative squeeze pressures >60 mmHg (n = 19) had improved postoperative fecal continence relative to those with lower pressures (incontinence rate, 10 vs. 54 percent; P = 0.004), despite having similar degrees of preoperative incontinence. Abnormalities of pudendal nerve function and mean resting pressures were not predictive of postoperative incontinence. Conclusions Perineal proctectomy provides relief from rectal prolapse, with good intermediate term results. Preoperative anal manometry can predict fecal continence rates after proctectomy, because patients with maximal squeeze pressures >60 mmHg have significantly improved outcomes. Supported exclusively using institutional funding. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

The Utility of Pudendal Nerve Terminal Motor Latencies in Idiopathic Incontinence

Purpose Pudendal nerve terminal motor latency testing has been used to test for pudendal neuropathy, but its value remains controversial. We sought to clarify the relationship of pudendal nerve terminal motor latency to sphincter pressure and level of continence in a cohort of patients with intact anal sphincters and normal pelvic floor anatomy. Methods We reviewed 1,404 consecutive patients who were evaluated at our pelvic floor laboratory for fecal incontinence. From this group, 83 patients had intact anal sphincters on ultrasound and did not have internal or external rectal prolapse during defecography. These patients were evaluated by pudendal nerve terminal motor latency testing, a standardized questionnaire, and anorectal manometry, which measured resting and squeeze anal pressures. Incontinence scores were calculated by using the American Medical Systems Fecal Incontinence Score. Values were compared by using the Fisher’s exact test and Wilcoxon’s rank-sum test; and significance was assigned at the P < 0.05 level. Results 1) Using a 2.2-ms threshold, 28 percent of patients had prolonged pudendal nerve terminal motor latency unilaterally and 12 percent bilaterally. 2) At a 2.4-ms threshold, 18 percent of patients had prolonged pudendal nerve terminal motor latency unilaterally and 8 percent bilaterally. 3) Bilaterally prolonged pudendal nerve terminal motor latency was significantly associated with decreased maximum mean resting pressure and increased Fecal Incontinence Score, but not decreased maximum mean squeeze pressure, at both 2.2-ms and 2.4-ms thresholds. 4) Unilaterally prolonged pudendal nerve terminal motor latency was not associated with maximum mean resting pressure, maximum mean squeeze pressure, or fecal incontinence score at either threshold. Conclusions The majority of incontinent patients with intact sphincters have normal pudendal nerve terminal motor latency. Bilaterally but not unilaterally prolonged pudendal nerve terminal motor latency is associated with poorer function and physiology in the incontinent patient with an intact sphincter. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004. Reprints are not available.     

Unilateral Pudendal Neuropathy is Common in Patients with Fecal Incontinence

Purpose Pudendal neuropathy and fecal incontinence frequently coexist; however, the contribution of neuropathy is unknown. The pudendal nerve innervates the external anal sphincter muscle, anal canal skin, and coordinates reflex pathways. Lateral dominance or a dominantly innervating nerve and its subsequent damage may have major implications in the etiology and treatment of fecal incontinence. This study was designed to establish the prevalence of pudendal neuropathy, in particular a unilateral one, and to examine the impact on anorectal function. Methods A total of 923 patients (745 females; mean age, 52 (range, 17–92) years) with fecal incontinence were studied using endoanal ultrasonography, anorectal manometry, rectal sensation, and pudendal nerve terminal motor latencies. Results A total of 520 patients (56 percent) demonstrated a pudendal neuropathy, which was unilateral in 38 percent (351 patients; 169 right-sided, 182 left-sided). Neuropathy, whether it was bilateral (bilateral vs. normal; 56 (range, 7–154) cm H₂O) vs. 67 (range, 5–215) cm H₂O; P < 0.01) or unilateral (unilateral vs. normal; 61 (range, 0–271) cm H₂O vs. 67 (range, 5–215) cm H₂O; P = 0.04) was associated with reduced anal resting tone. This also was seen with respect to squeeze increments (bilateral vs. normal; 34 (range, 0–207) cm H₂O vs. 52 (range, 0–378) cm H₂O; P < 0.001, unilateral vs. normal; 41 (range, 0–214) cm H₂O vs. 52 (range, 0–378) cm H₂O; P < 0.01). In those with intact sphincters, unilateral neuropathy was associated with reduced squeeze increments (unilateral vs. normal; 60 (range, 10–286) cm H₂O vs. 69 (range, 7–323) cm H₂O; P = 0.01) but no significant reduction in resting pressures. There was no association between pudendal neuropathy and abnormal rectal sensitivity. Conclusions Unilateral pudendal neuropathy is a common abnormality in individuals with fecal incontinence and is significantly associated with both attenuated resting pressures and squeeze increments. Although there are limitations in the interpretation of pudendal nerve terminal motor latencies, this study demonstrates that further exploration of the concept of lateral dominance is needed. Supported by a grant from Dunhill Medical Trust/Royal College of Surgeons. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006. Reprints are not available.     

Electrophysiologic and manometric assessment of failed postanal repair for anorectal incontinence

The reason for failure to improve fecal incontinence after postanal repair in idiopathic (neurogenic) anorectal incontinence is unknown. The authors have studied 20 patients whose anorectal continence was not improved after Parks' postanal repair. Anorectal manometry, single fiber EMG of the external anal sphincter muscle, and measurements of the pudendal nerve terminal motor latency were studied before and nine months after postanal repair. All 20 patients had evidence of reinnervation within the external anal sphincter muscle before operation; 17 had a raised pudendal nerve terminal motor latency and all 20 had low resting voluntary contraction anal canal pressures. No significant differences were found between the resting, voluntary contraction anal canal pressures and single fiber EMG fiber density values before or after postanal repair. However, a significant increase in the pudendal nerve terminal motor latency was found after postanal repair (P<0.001) using a student's pairedt test. These results suggest that, in patients who are not rendered continent by postanal repair, a continuing neuropathic process takes place. Read at the joint meeting of the American Society of Colon and Rectal Surgeons with the Section of Colo-Proctology of the Royal Society of Medicine and the Section of Colonic and Rectal Surgery of the Royal Australasian College of Surgeons, New Orleans, Louisiana, May 6–11, 1984.     

Phase II clinical trial of preoperative combined chemoradiation for T3 and T4 resectable rectal cancer: preliminary results

PURPOSE: Although preoperative chemoradiation for high-risk rectal cancer may improve survival and local recurrence rate, its adverse effects are not well defined. This prospective study evaluated the use of preoperative chemoradiation for T3 and T4 resectable rectal cancer, with special emphasis on treatment morbidity, pathologic remission rate, quality of life, and anorectal function. METHODS: Forty-two patients (30 men, 12 women) were enrolled in the study. Median distance of the distal tumor margin from the anal verge was 6.5 cm. Preoperative staging was based on digital rectal examination, endorectal ultrasound, and computed tomography. None of the patients had distant metastases. All patients had 45 Gy (1.8 Gy/day in 25 fractions) over five weeks, plus 5-fluorouracil (350 mg/m(2)/day) and leucovorin (20 mg/m(2)/day) bolus on days 1 to 5 and 29 to 33. Quality of life was assessed with the European Organization for Research and Treatment of Cancer 30-item quality-of-life questionnaire (QLQ-C30) and its colorectal cancer-specific module (QLQ-CR38) questionnaires. Objective anorectal function was assessed by anorectal manometry and pudendal nerve terminal motor latency. Surgery was performed 46 (range, 24-63) days after completion of adjuvant therapy. RESULTS: Nineteen patients (45 percent) had Grade 3 or 4 chemoradiation-induced toxic reactions. Four patients developed intercurrent distant metastases or intraperitoneal carcinomatosis at completion of chemoradiation. Thirty-eight patients underwent surgical resection: abdominoperineal resection, anterior resection, and Hartmann's procedure were performed in 55 percent, 39 percent (11 of 15 patients had a diverting stoma), and 5 percent, respectively. Major surgical complications occurred in 7 patients (18 percent) and included anastomotic leak (n = 1), pelvic abscess (n = 1), small-bowel obstruction (n = 3), and wound breakdown (n = 2). Final pathology was Stage 0 (no residual disease), I, II, and III in 6 (16 percent), 7 (18 percent), 9 (24 percent), and 16 (42 percent) patients, respectively. There was a deterioration, after chemoradiation and surgery, in the quality of life on all subscales assessed, with physical, role, and social function being most severely affected. The symptoms most adversely affected were micturition, defecation, and gastrointestinal problems. Body image and sexual enjoyment deteriorated in both men and women. Chemoradiation alone led to prolonged pudendal nerve terminal motor latency in 57 percent of 7 patients assessed. CONCLUSION: Preliminary results have identified defined costs with preoperative chemoradiation, which included treatment-induced toxicity, a high stoma rate, and adverse effects on quality of life and anorectal function.     

Effect of oral diazepam on anal continence after low anterior resection: a preliminary study

The aim of the present study was to investigate the effect of oral diazepam on anal incontinence after low anterior resection for rectal cancer. Five patients with persistent incontinence after low anterior resection for rectal cancer (median level of anastomosis was 4.0 cm from the anal verge) were treated with oral diazepam (2 mg/day) 9–90 months after surgery. Grade and frequency of anal incontinence, the need for a protective pad and changes of lifestyle were recorded to the Cleveland Clinic's continence grading scale; anorectal manometry was performed before and after 3 months of treatment. All patients improved on treatment although occasional minor soiling persisted in two patients. Continence score improved from 14 (median, range 9–16) to 0 (range 0–12) after taking diazepam. Improvement occurred within a week after administration of diazepam. Although the patients improved symptomatically, anorectal manometry failed to demonstrate any significant changes. In conclusion, oral administration of diazepam may be worthwhile in the attempt to improve anal continence after low anterior resection. Received: 20 September 2001 / Accepted in revised form: 6 December 2001     

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     

Anal inspection and digital rectal examination compared to anorectal physiology tests and endoanal ultrasonography in evaluating fecal incontinence

Background Anal inspection and digital rectal examination are routinely performed in fecal incontinent patients but it is not clear to what extent they contribute to the diagnostic work-up. We examined if and how findings of anal inspection and rectal examination are associated with anorectal function tests and endoanal ultrasonography. Methods A cohort of fecal incontinent patients (n=312, 90% females; mean age 59) prospectively underwent anal inspection and rectal examination. Findings were compared with results of anorectal function tests and endoanal ultrasonography. Results Absent, decreased and normal resting and squeeze pressures at rectal examination correlated to some extent with mean (±SD) manometric findings: mean resting pressure 41.3 (±20), 43.8 (±20) and 61.6 (±23) Hg (p<0.001); incremental squeeze pressure 20.6 (±20), 38.4 (±31) and 62.4 (±34) Hg (p<0.001). External anal sphincter defects at rectal examination were confirmed with endoanal ultrasonography for defects <90 degrees in 36% (37/103); for defects between 90-150 degrees in 61% (20/33); for defects between 150-270 degrees in 100% (6/6). Patients with anal scar tissue at anal inspection had lower incremental squeeze pressures (p=0.04); patients with a gaping anus had lower resting pressures (p=0.013) at anorectal manometry. All other findings were not related to any anorectal function test or endoanal ultrasonography. Conclusions Anal inspection and digital rectal examination can give accurate information about internal and external anal sphincter function but are inaccurate for determining external anal sphincter defects <90 degrees. Therefore, a sufficient diagnostic work-up should comprise at least rectal examination, anal inspection and endoanal ultrasonography.     

Squamous-Cell Carcinoma of the Rectum: A Rare but Curable Tumor

Purpose This study was designed to evaluate one institution’s experience with treatment outcomes for rectal squamous-cell carcinoma. Methods Using our prospective Colorectal Database, we identified patients diagnosed with rectal squamous-cell carcinoma at our institution between 1983 and 2005. Pathology was rereviewed, tumor immunophenotype was compared to control cases of anal squamous-cell carcinoma and rectal adenocarcinoma, treatment modalities and outcomes were analyzed. Results Twelve patients were identified (10 females median age, 58 years). Median distal extent of tumors was 7 (range, 5–8) cm from the anal verge. Treatment included chemotherapy only (n = 1), chemoradiation only (n = 2), induction chemotherapy followed by chemoradiation and surgery (n = 2), chemoradiation followed by surgery (n = 5), and surgery followed by chemoradiation (n = 2). The chemotherapy regimen was 5-fluorouracil-based. Radiotherapy total dose was 50.4 Gy (1.8 Gy/day, daily × 5) external iliac and inguinal nodes were not included in the radiation field. Complete clinical responders to chemoradiation (n = 2) received no further treatment. All seven partial responders underwent surgery; six had complete pathologic response; nodal status in two of six was unknown because they had local excision. Immunophenotypical analysis showed similar keratin expression profile between rectal squamous-cell carcinoma (n = 5) and rectal adenocarcinoma (n = 5), which is different from anal squamous-cell carcinoma (n = 10). All patients were alive without evidence of disease at follow-up (median follow-up, 2.6 (range, 0.5–16) years). Conclusions Our data suggest that most patients treated with upfront chemoradiation therapy followed by surgery did well. Sphincter-preserving surgery is usually feasible. Clinical judgment of tumor response after chemoradiation is not completely reliable. Immunohistochemistry suggests a common cellular origin for rectal squamous-cell carcinoma and rectal adenocarcinoma, which is different from anal squamous-cell carcinoma. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006. Reprints are not available.     

Pudendal nerve terminal motor latency influences surgical outcome in treatment of rectal prolapse

Purpose: This study was undertaken to document the effect of pudendal nerve function on anal incontinence after repair of rectal prolapse. METHODS: Patients with full rectal prolapse (n=24) were prospectively evaluated by anal manometry and pudendal nerve terminal motor latency (PNTML) before and after surgical correction of rectal prolapse (low anterior resection (LAR; n=13) and retrorectal sacral fixation (RSF; n=11)). RESULTS: Prolapse was corrected in all patients; there were no recurrences during a mean 25-month follow-up. Postoperative PNTML was prolonged bilaterally (>2.2 ms) in six patients (3 LAR; 3 RSF); five patients were incontinent (83 percent). PNTML was prolonged unilaterally in eight patients (4 LAR; 4 RSF); three patients were incontinent (38 percent). PNTML was normal in five patients (3 LAR; 2 RSF); one was incontinent (20 percent). Postoperative squeeze pressures were significantly higher for patients with normal PNTML than for those with bilateral abnormal PNTML (145 vs.66.5 mmHg; P =0.0151). Patients with unilateral abnormal PNTML had higher postoperative squeeze pressures than those with bilateral abnormal PNTML, but the difference was not significant (94.8 vs.66.5 mmHg; P=0.3182). The surgical procedure did not affect postoperative sphincter function or PNTML. CONCLUSION: Injury to the pudendal nerve contributes to postoperative incontinence after repair of rectal prolapse. Status of anal continence after surgical correction of rectal prolapse can be predicted by postoperative measurement of PNTML.Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Pelvic floor neuropathy: a comparative study of diabetes mellitus and idiopathic faecal incontinence.

Twenty one patients with diabetic peripheral neuropathy, 18 with idiopathic faecal incontinence and 11 normal controls were studied with techniques of mucosal electrosensitivity, rectal distension for the quantitative assessment of anorectal sensation, and manometric and electromyographic tests for the assessment of anorectal motor function. An asymptomatic sensorimotor deficit was found in the anal canal of patients with diabetic peripheral neuropathy. Mucosal electrosensitivity thresholds in the anal canal were significantly higher (p less than 0.01 v controls) and fibre density of the external anal sphincter significantly raised (p less than 0.0001 v controls). Anal manometry and pudendal nerve terminal motor latencies were similar to controls. In patients with idiopathic faecal incontinence the tests of sensory and motor function also showed a sensorimotor neuropathy; compared with controls, mucosal electrosensitivity thresholds were significantly higher (p less than 0.002), anal canal resting and maximum squeeze pressures were significantly lower (p less than 0.05 and p less than 0.002 respectively), and pudendal nerve terminal motor latencies and fibre density of the external anal sphincter were significantly raised (both p less than 0.05). Sensory thresholds to rectal distension were similar in all groups. Pelvic floor sensorimotor neuropathy in diabetic patients has several features in common with that of patients with idiopathic faecal incontinence but its functional significance remains uncertain.     

Influence of Intraoperative and Postoperative Radiotherapy on Functional Outcome in Patients Undergoing Standard and Deep Anterior Resection for Rectal Cancer

Purpose This study was designed to investigate the influence of intraoperative and postoperative radiotherapy on functional outcome after rectal resection for rectal cancer. Methods One hundred patients who underwent deep or standard anterior resection for rectal cancer were included in this follow-up study. All patients filled out questionnaires regarding morbidity and functional outcome; a subgroup (n = 63) underwent further clinical evaluation. The results were stratified according to radiation: Group I, no radiation (n = 37); Group II, only intraoperative radiation (n = 12); Group III, intraoperative and postoperative radiation (n = 51). Results Anal continence measured by Kirwan-Parks classification and Wexner score was significantly different within the three groups (P < 0.005, P < 0.0001), whereas continence impairment was least in Group I and greatest in Group III. Patients in Group III demonstrated a significantly worsecategory in the Kirwan-Parks classification and worse Wexner scores compared with patients in Group I (P < 0.0001). Patients only having undergone intraoperative radiotherapy had a significantly worse continence (Kirwan-Parks classification) than patients without any radiotherapy (P < 0.05). More patients after intraoperative and postoperative radiation therapy complained of fragmented stools (P < 0.05) and urgency (P < 0.05) compared with patients only having undergone surgery; the need towear pads was higher (P = 0.001). Vector volume manometry revealed better resting sphincter function in Group I compared with Group III (P ≤ 0.005). Conclusions Patients with anterior resection for rectal cancer who undergo full-dose radiotherapy have significantly more impairment of anorectal function than patients without radiotherapy. Patients who were only exposed to intraoperative radiotherapy showed moderate impairment of continence function, suggesting that the influence of radiotherapy on anal function may be dose-dependent and application-dependent.     

Effect of Aging on Anorectal and Pelvic Floor Functions in Females

Purpose In females, fecal incontinence often is attributed to birth trauma; however, symptoms sometimes begin decades after delivery, suggesting that anorectal sensorimotor functions decline with aging. Methods In 61 asymptomatic females (age, 44 ± 2 years, mean ± standard error of the mean) without risk factors for anorectal trauma, anal pressures, rectal compliance, and sensation were assessed by manometry, staircase balloon distention, and a visual analog scale during phasic distentions respectively. Anal sphincter appearance and pelvic floor motion also were assessed by static and dynamic magnetic resonance imaging respectively in 38 of 61 females. Results Aging was associated with lower anal resting (r = −0.44, P < 0.001) and squeeze pressures (r = −0.32, P = 0.01), reduced rectal compliance (i.e., r for pressure at half-maximum volume vs. age = 0.4, P = 0.001), and lower (P ≤ 0.002) visual analog scale scores during phasic distentions at 16 (r = −0.5) and 24 mmHg (r = −0.4). Magnetic resonance imaging revealed normal anal sphincters in 29 females and significant sphincter injury, not associated with aging, in 9 females. The location of the anorectal junction at rest (r = 0.52, P < 0.001), squeeze (r = 0.62, P < 0.001), and Valsalva maneuver (r = 0.35, P = 0.03), but not anorectal motion (e.g., from resting to squeeze) was associated with age. Conclusions In asymptomatic females, aging is associated with reduced anal resting and squeeze pressures, reduced rectal compliance, reduced rectal sensation, and perineal laxity. Together, these changes may predispose to fecal incontinence in elderly females. Supported in part by Grants R01 HD38666, R01 HD41129, and R01 EB00212 (SJR) and General Clinical Research Center grant M01 RR00585 from the National Institutes of Health, U.S. Public Health Service. Presented at the meeting of the American Gastroenterological Association, Atlanta, Georgia, May 20 to 23, 2001. An erratum to this article is available at .     

Results of neurophysiologic evaluation in fecal incontinence

PURPOSE: Several methods of neurophysiologic assessment exist in the investigation of patients with fecal incontinence. However, the clinical significance of the information gained is uncertain. The aim of this prospective study was to evaluate the results of pudendal nerve terminal motor latency and fiber density in relation to clinical variables and manometric measurements. METHODS: Seventy-two patients with fecal incontinence (63 women; mean age, 62; range, 24–81 years) responded to a bowel questionnaire and underwent anorectal manovolumetry, anal ultrasonography, defecography, and electromyography, including pudendal nerve terminal motor latency and fiber density. RESULTS: Pudendal neuropathy (pudendal nerve terminal motor latency >2.5 ms) was found in 46 percent and increased fiber density (>1.7) in 82 percent. Pudendal neuropathy and increased fiber density were most common in patients with rectal prolapse or intra-anal intussusception. No difference was seen concerning anal resting and incremental pressures, rectal compliance, rectal sensibility or severity of incontinence in patients with unilateral, bilateral, or marked (>4 ms) pudendal neuropathyvs. patients with normal pudendal nerve terminal motor latency. In contrast, patients with increased fiber density had lower incremental pressures (P<0.05) and stated decreased rectal sensibility (P<0.05) compared with those with normal fiber density. These differences were most pronounced in patients with neurogenic or idiopathic incontinence. CONCLUSIONS: Pudendal neuropathy and increased fiber density are common in patients with fecal incontinence. Fiber density but not pudendal nerve terminal motor latency was correlated with clinical and manometric variables. The severity of nerve injury correlated with anal motor and sensory function in patients with neurogenic or idiopathic incontinence. The routine use of pudendal nerve terminal motor latency in the assessment of patients with fecal incontinence can be questioned.Read at The American Society of Colon and Rectal Surgeons' 100th Anniversary and Tripartite Meeting, Washington, D.C., May 1 to 6, 1999.     

Effect of neoadjuvant chemoradiation on postoperative fecal continence and anal sphincter function in rectal cancer patients

Background and aims Neoadjuvant chemoradiation (nCRT) followed by curative surgery has gained acceptance as the therapy of choice in locally advanced rectal cancer. This prospective study evaluates the effect of nCRT on postoperative anorectal function and continence. Patients and methods Group A consisted of 12 patients (59.8 ± 11.9 years, male:female = 8:4) who received nCRT (5-FU, CPT-11. 45 + 5.4 Gy boost) before surgery and Group B of 27 patients (61.9 ± 10.6 years, male:female = 16:11) who were treated by surgery alone. All patients received a questionnaire to evaluate stool continence and anorectal function before as well as after surgery. Anorectal function was further analyzed by perfusion manometry pre- and postoperatively. Results Preoperatively, none of the patients had signs or symptoms of fecal incontinence, and preoperative measurements showed values within normal limits. Postoperatively, fecal continence was impaired in both groups, but no significant difference was found between patients with or without nCRT. Anorectal manometry revealed an impairment of anorectal function after low anterior resection regardless of the treatment regime. Conclusion nCRT does not impair anorectal function and fecal continence. The deterioration of continence and anal sphincter function after sphincter preserving surgery is solely caused by the surgical procedure.     

Rehabilitation of Fecal Incontinence After Sphincter-Saving Surgery for Rectal Cancer: Encouraging Results

Purpose  Some patients, having undergone sphincter-saving operations for rectal cancer, may suffer from fecal incontinence. This study was designed to evaluate the results of rehabilitative treatment in patients with fecal incontinence after sphincter-saving operations and to identify the negative factors that influence therapeutic success. Methods  Between January 2000 and June 2007, 88 incontinent patients (54 women; age range, 47–73 years; 69 had received a low anterior rectal resection; 19 a straight coloanal anastomosis) were included in the study. After a preliminary clinical evaluation, including the Wexner Incontinence Scale score, anorectal manometry was performed. All 88 patients underwent rehabilitative treatment according to the “multimodal rehabilitative program” for fecal incontinence. At the end of program, all 88 patients were reassessed by means of a clinical evaluation and anorectal manometry; their results were compared with the clinical and manometric data from ten healthy control subjects. Postrehabilitative Wexner Incontinence Scale scores were used for an arbitrary schedule of patients divided into three classes: Class I, good (score ≤3); Class II, fair (score >3 to ≤6); Class III, poor (score >6). Results  After rehabilitation, there was a significant improvement in the overall mean Wexner Incontinence Scale score (P < 0.03) for both surgical operation types (low anterior rectal resection: P < 0.05; coloanal anastomosis: P < 0.02). Only 21 patients (23.8 percent) were symptom-free, and 37 (42 percent) were considered Class III. A significant postrehabilitative direct correlation was found between: 1) Wexner Incontinence Scale score and degree of genital relaxation (rρ _s 0.78; P < 0.001); 2) Wexner Incontinence Scale score and irradiation (rρ _s 0.72; P < 0.01); and 3) Wexner Incontinence Scale score and pelvic (rρ _s 0.65; P < 0.01) or anal surgery (rρ _s 0.68; P < 0.01). No significant differences were found between prerehabilitative and postrehabilitative anal pressures in low anterior rectal resection and coloanal anastomosis patients. Conclusions  After rehabilitation, some patients become symptom-free, many patients show an improvement in the Wexner Incontinence Scale score, and others exhibit the highest grades of fecal incontinence. Genital relaxation, radiotherapy, and previous pelvic, and/or anal surgery are impeding factors to rehabilitative success.     

Transanal endoscopic microsurgery excision: is anorectal function compromised?

PURPOSE: Transanal endoscopic microsurgery is a new technique that has not yet found its place in routine practice. The procedure results in dilation of the anal sphincter with a large-diameter operating sigmoidoscope, sometimes for a prolonged period. The purpose of the present study was to assess the effect of transanal endoscopic microsurgery on anorectal function. METHODS: Eighteen consecutive patients undergoing transanal endoscopic microsurgery excision of rectal tumors, of whom 13 were available for evaluation, were included. Continence was scored by a numeric scale before surgery and at three and six weeks after surgery. Anorectal physiology studies were performed preoperatively and six weeks postoperatively with manometry, pudendal nerve motor terminal latency, anal mucosal electrosensitivity, rectal balloon volume studies, and endoanal ultrasound. RESULTS: There was a significant reduction in mean anal resting pressure (104 ± 32 cm H2O before surgery, 73 ± 30 cm H2O after surgery; P = 0.0009). There was no significant change in squeeze or cough pressure, pudendal nerve terminal motor latency, anal mucosal electrosensitivity, or rectal balloon study volumes. Fall in resting pressure was significantly correlated with length of operating time (r2 =0.39, P = 0.047). There was no significant change in mean continence score after surgery. CONCLUSION: Transanal endoscopic microsurgery results in a reduction in internal sphincter tone. This did not affect continence in a short-term study.     

Anorectal incontinence and rectal prolapse: differential assessment of the innervation to puborectalis and external anal sphincter muscles.

The innervation of the puborectalis and external anal sphincter muscles was studied in 32 patients with idiopathic (neurogenic) faecal incontinence, 12 of whom also had complete rectal prolapse, using transcutaneous spinal stimulation, transrectal pudendal nerve stimulation, single fibre EMG, anorectal manometry, and measurement of perineal descent. Fourteen normal subjects served as controls. Significant increases in the spinal motor latencies from L1 to the puborectalis and external anal sphincter muscles were shown in all 32 incontinent patients (p less than 0.01). The single fibre (EMG) fibre density was increased in the puborectalis muscle in 60% and in the external anal sphincter in 75% of patients. An increased pudendal nerve terminal motor latency was found in 68% of patients; 69% had an abnormal degree of perineal descent and all had reduced anal canal contraction pressures. These data show that the different innervations of the puborectalis and external anal sphincter muscles are both damaged in patients with anorectal incontinence.