Injury to innervation of pelvic floor sphincter musculature in childbirth

71 women delivered at St Bartholomew's Hospital, London, were studied by electrophysiological tests of the innervation of the external anal sphincter muscle and by manometry. The investigations were done 2-3 days after delivery and again, in 70% of these women, 2 months later. Faecal and urinary incontinence developing after vaginal delivery has been thought to be due to direct sphincter division, or muscle stretching, but the results of the study suggest that in most cases this incontinence results from damage to the innervation of the pelvic floor muscles.     

Geriatrische Patientinnen mit Harninkontinenz-Symptomen und ihre Kontrolle über den Beckenboden

Not only do anatomy and function of the pelvic floor play an important role as possible causes of female urinary incontinence, they are also crucial for its therapy. The aim of this case control study of female geriatric patients with symptoms of urinary incontinence was to determine the knowledge about their pelvic floor and to assess their ability to contract pelvic floor muscles voluntarily and reflexly. METHODS: A total of 377 female geriatric patients with symptoms of urinary incontinence were investigated in a Basis Assessment for Urinary incontinence. The ability to contract their pelvic floor muscles was examined by a digital vaginal palpation. The extent of the registered muscle strength was graded by the Modified Oxford Grading Scale by Laycock (1994). RESULTS: Of the patients, 65.5% were not aware of their pelvic floor and were not able to contract the pelvic floor muscles (Grade 0 to 1 by Laycock), 22% had an inaccurate knowledge and only performed an insufficient pelvic floor muscle contraction (Grade 2 by Laycock). Only 12.5% could contract their pelvic floor muscles properly (Grade 3 to 4 by Laycock). A subgroup of 83 patients had already absolved pelvic floor exercises in the past, 80 patients with conventional instructions, 3 patients with digital vaginal control. In this subgroup 54.2% of the patients were not able to contract the pelvic floor muscles (Grade 0 to 1 by Laycock) 25.3% only performed an insufficient contraction (Grade 2 by Laycock), while 20% were able to perform a sufficient and powerful contraction (Grade 3 to 4 by Laycock). The three patients in the past controlled by a digital vaginal palpation were part of this group and managed a pelvic floor muscle strength Grade 4 by Laycock. A high percentage of female geriatric patients with symptoms of urinary incontinence have a lack of understanding regarding the position and function of their pelvic floor. These results suggest that conventional pelvic floor muscle exercises without specific control are not an appropriate method to improve geriatric patients' ability to contract their pelvic floor muscles and to prevent urine leakage.     

Usefulness of anorectal and endovaginal 3D ultrasound in the evaluation of sphincter and pubovisceral muscle defects using a new scoring system in women with fecal incontinence after vaginal delivery

Purpose

This study aims to evaluate pubovisceral muscle and anal sphincter defects in women with previous vaginal delivery and fecal incontinence and to correlate the findings with the severity of symptoms using the combined anorectal and endovaginal 3D ultrasonography with a new ultrasound scoring system.

Methods

Consecutive female patients with previous vaginal delivery and fecal incontinence symptoms were screened. Fecal incontinence was assessed with the Cleveland Clinic Florida fecal incontinence scale, and the extent of defects was assessed by an ultrasound score based on results of anorectal and endovaginal 3D ultrasound. Fecal incontinence was assessed with the Cleveland Clinic Florida fecal incontinence scale.

Results

Of 84 women with previous vaginal delivery and fecal incontinence, 21 (25%) had intact pubovisceral muscles and anal sphincters; 63 (75%) had a pubovisceral muscle or anal sphincter defect, or both. Twenty-eight (33%) had a pubovisceral muscle defect [23% with an external anal sphincter (EAS) defect or combined EAS/internal anal sphincter defects; 11% with intact anal sphincters]. Thirty-five (42%) had intact pubovisceral muscles and an anal sphincter defect. Compared with women with intact pubovisceral muscles/anal sphincter defects, patients with pubovisceral muscle defects had significantly higher incontinence scores and significantly higher ultrasound scores indicating more extensive defects. Incontinence symptoms correlated positively with the ultrasound score, measurements of sphincter defects, and area of the levator hiatus.

Conclusions

Evaluation of both pubovisceral muscles and anal sphincters is important to identify defects and determine treatment for women with fecal incontinence after vaginal delivery. The severity of fecal incontinence symptoms is significantly related to the extent of defects of the pubovisceral muscles and anal sphincters.

     

Clinical experiences of five cases with ulcerative colitis and recto- or anovaginal fistula]

Clinical aspects, treatment and outcome of five patients with ulcerative colitis recto- or anovaginal fistula and were studied retrospectively. All patients had total colitis (relapse and remission type) and more than a 5 year history of ulcerative colitis. They all had anorectal complications, such as periproctal abscess, stenosis of fistula. Four patients had total colectomy with an ileal pouch anal canal anastomosis for intractability or dysplasia. One was treated conservatively. Complete closure of fistula was obtained in two patients;in one patient rectum was resected below the fistula and in one patient defect of the vaginal posterior wall was reconstructed by using a gluteal fold flap following colectomy. Recto- or anovaginal fistula complicating ulcerative colitis is rare but may occur in the patients with severe rectal inflammation and they can be managed by restorative proctocolectomy with an ileal pouch anal or anal canal anastomosis.     

Ileal pouch anal anastomosis: an overview of surgery, recovery, and achieving postsurgical continence

Ileal pouch anal anastomosis (IPAA) is a two- or three-stage surgical procedure performed to treat patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP). Following ileostomy closure and anastomosis, patient goals of care typically include obtaining continence and preventing complications. Nursing interventions to achieve these goals may include developing a skin care regimen, pelvic muscle floor exercises (PFME), diet changes, medication use and coping strategies. Research suggests that patient quality of life following surgery is generally good, especially in patients with a functioning pouch or a history of severe UC and a functioning pouch. However, the procedure is relatively new, and long-term (>20 years) outcomes remain largely unknown. Ongoing assessments to monitor complications such as pouchitis and pouch stricture are needed, as is research to determine the long-term effects of vaginal delivery and of living into the seventh, eighth, and ninth decades of life.     

Vaginal endosonography

PURPOSE: Although anal endosonography provides clear images of anal sphincters, the probe in the anal canal may distort epithelial structures and sphincter muscles may be compressed, producing inaccurate muscle thickness measurements. The aim of this study is to describe a new approach using vaginal endosonography to image the anal canal undistorted. METHODS: Twenty females (10 healthy volunteers and 10 with fecal incontinence) had both anal and vaginal endosonography performed. RESULTS: The undisturbed anorectum, submucosa, anal cushions, and anal sphincter muscles were clearly visualized by vaginal endosonography, and anatomy was described. Although anal and vaginal endosonographic measurements of internal sphincter muscle thickness correlated (r=0.83;P=0.01), anal endosonography consistently underestimated the thickness (2.3±0.5 vs. 3.2±1.2 mm; mean ± standard deviation). Anterior internal and external anal sphincter defects were identified accurately with both techniques. CONCLUSIONS: Vaginal endosonography is a new technique that enables accurate imaging of anal sphincters and epithelial structures at rest. In addition to making the diagnosis of anal sphincter defects, it has potential applications in the imaging of anovaginal sepsis and malignancy and possibly in understanding the pathogenesis of anal fissure and hemorrhoids.Read at The Annual Scientific Congress of the Royal Australasian College of Surgeons, Adelaide, Australia, May 10 to 14, 1993.Dr. Sultan was supported by the Joint Research Board and the Directorate of Obstetrics and Gynaecology, St. Bartholomew's Hospital.Dr. Kamm was supported by The Research Foundation, St. Mark's Hospital, London, United Kingdom.     

Advances in the surgical management of anal incontinence.

The standard treatments for traumatic and idiopathic faecal incontinence have for the last 10-15 years been sphincter reconstruction and pelvic floor repair, respectively. Results of the treatment of traumatic sphincter lesions have in general been satisfactory, whereas the results after prolonged follow-up of pelvic floor repair for idiopathic anal incontinence seem less convincing. Incontinence due to neurological disorders cannot always be treated by local procedures on the anal sphincter or pelvic floor. This has led to the investigation of a number of other surgical procedures with the aim of re-establishing faecal continence. These include transposition of striated muscles, primarily the gracilis and gluteus maximus, implantation of neuromuscular stimulators, implantation of artificial sphincters and implantation of neuroprosthesis. These new techniques, which are also applicable in patients with traumatic and idiopathic anal incontinence where local reconstructive procedures have failed, are reviewed in this chapter in the light of our present state of knowledge.     

Internal anal sphincter in neurogenic fecal incontinence

In neurogenic fecal incontinence there is denervation of the external anal sphincter and pelvic floor muscles but the role of the internal anal sphincter is incompletely understood. We have evaluated the internal anal sphincter in 6 patients with neurogenic incontinence undergoing postanal repair and in 7 control subjects. All the incontinent subjects, but none of the controls, had evidence of pudendal neuropathy. Surface electromyography studies of the internal anal sphincter showed absence of electrical activity in 4 of 6 incontinent subjects; in the remaining 2 subjects and in 6 of 7 controls normal slow waves were present. Internal sphincter muscle strips from control subjects showed normal in vitro responses to noradrenaline, isoprenaline, dimethyl-phenylpiperazinium, and electrical field stimulation; muscle strips from the incontinent patients showed complete insensitivity except in 2 patients in whom there was contraction to noradrenaline and relaxation to isoprenaline. Electron microscopy showed normal smooth muscle in 5 control subjects and minor changes in 1 subject; all the incontinent patients showed abnormalities in the smooth muscle cells of the internal anal sphincter. These findings indicate that in neurogenic fecal incontinence neurogenic weakness of the external anal sphincter and pelvic floor muscles is associated with damage to the internal anal sphincter.     

Magnetic resonance imaging of anatomic and dynamic defects of the pelvic floor in defecatory disorders

OBJECTIVE: Endoanal ultrasound identifies anal sphincter anatomy, and evacuation proctography visualizes pelvic floor motion during simulated defecation. These complementary techniques can evaluate obstructed defecation and fecal incontinence. Our aim was to develop a single, nonionizing, minimally invasive modality to image global pelvic floor anatomy and motion. METHODS: We studied six patients with fecal incontinence and seven patients with obstructed defecation. The anal sphincters were imaged with an endoanal magnetic resonance imaging (MRI) coil and endoanal ultrasound (five patients). MR fluoroscopy acquired images every 1.4-2 s, using a modified real-time, T2-weighted, single-shot, fast-spin echo sequence, recording motion as patients squeezed pelvic floor muscles and expelled ultrasound gel; no contrast was added to other pelvic organs. Six patients also had scintigraphic defecography. RESULTS: Endoanal ultrasound and MRI were comparable for imaging defects of the internal and external sphincters. Only MRI revealed puborectalis and/or external sphincter atrophy; four of these patients had fecal incontinence. MR fluoroscopy recorded pelvic floor contraction during squeeze and recorded relaxation during simulated defecation. Corresponding comparisons for angle change and perineal descent during defecation were not significant; only MRI, but not scintigraphy, identified excessive perineal descent in two patients. CONCLUSIONS: Pelvic MRI is a promising single, comprehensive, nonradioactive modality to measure structural and functional pelvic floor disturbances in defecatory disorders. This method may provide insights into mechanisms of normal and disordered pelvic floor function in health and disease.     

Transverse pelvic floor division for the posterior approach to the rectum and anus

The posterior approach to the rectum can be enhanced by a transverse division of the pelvic floor muscles. In a series of 51 patients the pelvic floor between the anus and the coccyx was opened in a transverse direction giving access to the pelvirectal space and the sphincter muscles. The approach which enabled an extensive exposure was used for posterior rectotomy (10 cases), nodal excision from the mesorectum and lateral ligaments (2 cases), postanal repair (3 cases), exploration or excision of complex high anal fistula (4 cases), abdomino-trans-sphincteric resection of rectal carcinoma (13 cases) and local excision (19 cases). The results with respect to wound healing and anorectal function were satisfactory.     

Funktionelle Darmentleerungsstörungen aus neurologischer Sicht

Chronic constipation can be caused by a slow transit constipation or an outlet obstruction. There can be various neuromuscular reasons for functional outlet obstruction. A paradox contraction or a lack of relaxation of the striated pelvic floor muscles occurs. Until now, the expression anismus is frequently used without differentiating according to the underlying pathophysiology. In principle, 3 disturbances can be differentiated: ferentiated: 1. The most common reason for the functional outlet obstruction is the inadequate coordination of the voluntary anal sphincters. When straining or during defecation there is a contraction of the external anal sphincter and/or of the puborectal muscle. There is no relevant organic damage of the nerves or muscles. Therapeutically, good results can be achieved with a behavioral therapy like biofeedback. 2. Spasticity of the striated pelvic floor muscles wich is caused by a lesion of the upper motoneuron, in most cases spinally localized, is another reason. Therapeutically, mainly local botulinum toxin injections are applied. 3. A more unusual reason is the dystonia of the striated sphincter of the pelvis. This is an extrapyramidal disorder which occurs either only locally or also generally. Therapeutically, local botulinum toxin injections are applied. In our opinion the term anismus should be restricted to this disorder. The reason for a function-al outlet obstruction should be found out so that a therapy can be made which is oriented on the underlying pathophysiology. A uniform nomenclature is urgently required.     

Neuromodulation for the Treatment of Lower Urinary Tract Symptoms

Neuromodulation therapy incorporates electrical stimulation to target specific nerves that control lower urinary tract symptoms (LUTS). The objectives of this article are to review the mechanism of action, the type of neuromodulation, and the efficacy of neuromodulation mainly according to the results of randomized controlled trials. Neuromodulation includes pelvic floor electrical stimulation (ES) using vaginal, anal and surface electrodes, interferential therapy (IF), magnetic stimulation (MS), percutaneous tibial nerve stimulation, and sacral nerve stimulation (SNS). The former four stimulations are used for external periodic (short‐term) stimulation, and SNS are used for internal, chronic (long‐term) stimulation. All of these therapies have been reported to be effective for overactive bladder or urgency urinary incontinence. Pelvic floor ES, IF, and MS have also been reported to be effective for stress urinary incontinence. The mechanism of neuromodulation for overactive bladder has been reported to be the reflex inhibition of detrusor contraction by the activation of afferent fibers by three actions, i.e., the activation of hypogastric nerve, the direct inhibition of the pelvic nerve within the sacral cord and the supraspinal inhibition of the detrusor reflex. The mechanism of neuromodulation for stress incontinence is contraction of the pelvic floor muscles through an effect on the muscle fibers as well as through the stimulation of pudendal nerves. Overall, cure and improvement rates of these therapies for urinary incontinence are 30–50, and 60–90% respectively. MS has been considered to be a technique for stimulating nervous system noninvasively. SNS is indicated for patients with refractory overactive bladder and urinary retention.     

Colonic and Anorectal Motility Testing in Clinical Practice

Colonic and anorectal motor activity can be evaluated by a variety of diagnostic techniques. These include anorectal and colonic manometry, radiographic and scintigraphic studies of defecation and continence, colonic transit using radioopaque markers or radioiso-topes, neurophysiological studies of pelvic floor striated muscles and pudendal nerves, and anal endosonography. This article reviews these techniques and assesses their value and limitations in evaluating patients with constipation, defecatory disorders, and fecal incontinence.     

Outpatient protocol for biofeedback therapy of pelvic floor outlet obstruction

Pelvic floor outlet obstruction is a rare cause of severe constipation. Anal myectomy, subtotal colectomy, and medical therapy have limited success. The purpose of this study was to develop a short outpatient treatment using biofeedback techniques. Nine patients with severe constipation and straining resulting from pelvic floor outlet obstruction underwent complete investigation of the pelvic floor musculature and anal sphincter mechanism. Patients were unable to expel a 60-cc rectal balloon and had nonrelaxing puborectalis on defecography. The treatment protocol utilized anal surface electromyography to document improper straining and retrain pelvic floor muscles to relax during defecation. Sensory retraining with a rectal balloon, behavioral relaxation techniques, and defecation of simulated stool using a 120-cc Metamucil^® (Procter & Gamble, Cincinnati, OH) slurry in the rectum allowed re-establishment of normal defecation in all nine patients. Repeat training was required in three patients during follow-up. Treatment of pelvic floor outlet obstruction with outpatient retraining techniques is possible.Read at the meeting of The American College of Gastroenterology, San Francisco, California, October 1990.     

Clinical neurophysiology and electrodiagnostic testing of the pelvic floor

This article summarizes our current understanding of the neuroanatomy and neurophysiology of the pelvic floor. The electrodiagnostic evaluation of the pelvic floor muscles and external anal sphincter, including pudendal nerve conduction studies, sacral reflexes, and needs EMG is presented. The discussion reviews the test methodology, the strengths and limitations of each test, and their clinical utility. The authors have tried to critically review the objective evidence to support the use of electrodiagnostic tests in the evaluation and management of pelvic floor disorders. The reader will have a better understanding of the rationale, methodology, clinical utility, and potential pitfalls for each of the commonly used neurophysiological tests of the pelvic floor.     

Solitary rectal ulcer syndrome in children

SRUS is a rare condition in children, which usually presents with a symptom complex of rectal bleeding, passage of mucus and straining on defecation, tenesmus, perineal and abdominal pain, sensation of incomplete defecation, constipation and rectal prolapse. The underlying etiology of SRUS is not fully understood but it is likely to be secondary to ischemic changes in the rectum associated with paradoxical contraction of pelvic floor and external anal sphincter muscles and rectal prolapse. Conservative measures like high intake of fluids and fibers, laxatives, biofeedback and behavior modification therapy may be beneficial for treatment of constipation. Excision of rectal ulcer and surgery of overt rectal prolapse, however, may be required in refractory cases not responding to conservative treatments. A therapeutic role for botulinum toxin injection into the external anal sphincter for treatment of SRUS associated with constipation and paradoxical contraction of pelvic floor and external anal sphincter muscles in children, may exist.     

Biofeedback therapy for dyssynergic defecation

INTRODUCTION Chronic constipation is a common self-reported bowel symptom that affects 2%-30% of people in Western countries and has considerable impact on health expenses and quality of life[1]. Most patients respond either to fiber- fluid supplementatio…     

Urinary stress incontinence in women

The integral theory of Petros and Ulmsten has profoundly changed our understanding of the female pelvic floor. Anatomic laxity of the vaginal wall caused by pelvic floor defects induced at different damage zones is frequently not only responsible for stress urinary incontinence but also for pollakisuria, urgency, post-void residual and pelvic pain. A number of minimally invasive techniques have been developed to correct these defects. Applying a tension-free polypropylene tape around the mid-urethra has become an established method to correct the anterior ligaments. The infra-coccygeal sacropexy can achieve dorsal stabilization of the vaginal wall. Currently, polypropylene meshes are increasingly used for repairing supporting pelvic fasciae. The most recommended conservative methods are exercises to strengthen the pelvic floor muscles. Duloxetine increases the rhabdosphincter contractility during the filling phases, but not during voiding, and therefore is a promising drug for clinical use.     

Pelvic floor disturbance after childbirth: vaginal delivery damages the upper levels of sphincter innervation

PURPOSE: Vaginal delivery disturbs pelvic floor innervation, which has previously been studied as a single mechanism. The effects of childbirth on innervation at different levels of the anal sphincter system were studied after childbirth. METHODS: Both anal manometry and motor latencies were measured in 67 females. Twenty-nine females (30.8±4.4 years) were examined four days after vaginal delivery. Eleven of these 29 females were re-examined five months after vaginal delivery. Nineteen females (33.6±4.6 years) who were examined five to nine days after undergoing an elective cesarean section and 19 asymptomatic, nonpregnant females (26.8±6.9 years) served as controls. Motor latencies were bilaterally measured within the anal sphincter system at 5, 3.8, 2.6, and 1.5 cm from the perineal skin by using a concentric needle electrode after sacral magnetic stimulation. Means of the bilateral latencies were analyzed. RESULTS: In postpartum females who gave birth vaginally, motor latencies at 5 and 3.8 cm, although not those at 2.6 and 1.5 cm, from the perineal skin were significantly prolonged, and anal pressure monitored by maximum resting and squeeze pressures was significantly decreased compared with that in control females. The decreased anal pressure normalized spontaneously. The prolonged motor latencies at the upper two levels of the anal sphincter system persisted in these females for five months after vaginal delivery. CONCLUSIONS: The disturbance of innervation of the upper anal sphincter system after vaginal delivery may last for a long time, whereas the decreased anal pressure normalizes in a short time. The protracted disturbance of innervation of the upper anal sphincter system may be associated with later development of fecal incontinence.Dr. Tomoyuki Sato was supported by both the 1998 Young Investigator Award of Jichi Medical School and the Scientific Research Fund from the Japanese Ministry of Education.Presented at the meeting of the Japan Proctology Association, Fukuoka, Japan, October 15 to 16, 1998. Published in abstract form in J Jpn Soc Coloproctol 1998;51:1016.     

Incidence and obstetric risk factors of postpartum anal incontinence

BACKGROUND: Anal incontinence in young women may be the result of injury to the pelvic floor during vaginal delivery. This study was conducted to evaluate the relationship between obstetric risk factors and the prevalence of anal incontinence 3 months and 1 year after delivery. METHODS: Three hundred consecutive women who delivered in the obstetric ward of the Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, were prospectively interviewed 3 months postpartum with regard to the symptom of anal incontinence. Patients with anal incontinence that started after delivery were questioned about the type, frequency, and severity of the problem, concomitant stress urinary incontinence (SUI), previous colorectal assessment, and wish for further evaluation and treatment. Obstetric data were collected from the women's medical charts. Symptomatic patients were followed-up 1 year postpartum. RESULTS: Anal incontinence was reported by 21 patients: 19 were incontinent to gas, whereas only 2 patients were incontinent to solid feces (6.3% and 0.7% of the study population, respectively). Five patients (24% of the anal-incontinent patients) also had concomitant SUI. The length of the first and second stages of labor, operative vaginal delivery, and episiotomy were found to be associated (P < 0.05) with the development of anal incontinence at 3 months postpartum. At I year postpartum all patients with combined anal incontinence and SUI had persistent symptoms. CONCLUSION: The major obstetric risk factors for postpartum anal incontinence are prolonged first and second stages of labor, operative vaginal delivery, and the use of episiotomy.