Anal acoustic reflectometry: a new technique for assessing anal sphincter function

Objective Anal acoustic reflectometry (AAR) is a new technique that offers an assessment of anal sphincter function by the measurement of additional parameters not available with conventional manometry. The aim of this study is to describe the technique, methodology and initial pilot study results. Method Wideband sounds (100 Hz to 16 kHz) are transmitted into a thin polyurethane bag placed within the anal canal. Calculation of cross‐sectional area from reflected sound waves, over a range of pressures (0–200 cm H₂O) during inflation/deflation of the bag, results in five physiological parameters of anal canal function. Five patients [three continent (two female) and two incontinent (both female)] were assessed with AAR and anal manometry. Results Anal acoustic reflectometry parameters were reduced in incontinent when compared with continent patients. Resting Opening Pressures (cmH₂O) were 27 and 16 in patients with faecal incontinence (FI) vs 44 and 72 in continent patients; Resting Opening Elastance (cmH₂O/mm²) was 0.88 and 1.08 in FI patients vs 1.65 and 1.34 in continent patients. The Resting Opening Pressure of a similarly aged continent male (55 cmH₂O) was greater than three of the females. During assessment of voluntary contraction (one FI female vs one continent female), Squeeze Opening Pressure (cmH₂O) was 31 vs 100 and Elastance (cmH₂O/mm²) 0.61 vs 2.07. Conclusion Anal acoustic reflectometry appears to be promising technique. Further work is in place to clarify whether it will be useful in clinical assessment of incontinent patients.     

Anorectal function in Crohn's disease.

Anorectal function was assessed in 63 patients with Crohn's disease and in 10 controls. Eleven patients with Crohn's disease (17%) were partially and three (5%) totally incontinent. The results of anal sphincter function studies of continent patients with Crohn's disease were similar to those of partially incontinent patients and controls. Incontinent patients had significantly lower maximal basal pressure (P less than 0.01) and significantly lower maximal squeeze pressure (P less than 0.05) as compared to controls. There was no significant difference in rectal capacity between continent, partially incontinent and totally incontinent patients and controls. There were significantly more patients with symptoms of anal incontinence in the group of patients with anal Crohn's disease as compared to the Crohn's group with normal anorectum (P less than 0.001). Risk factors for total anal incontinence in Crohn's disease were severe anorectal stenosis and previous surgery for anal abscesses. The most important reason for partial incontinence was diarrhoea. In conclusion, Crohn's disease without macroscopic lesions in the anorectum and without diarrhoea does not affect anorectal function.     

Anal sphincter defects and anal incontinence symptoms after repair of obstetric anal sphincter lacerations in primiparous women

A study was carried out to identify (1) incidence of anal incontinence symptoms, (2) incidence and size of both external anal sphincter (EAS) and internal anal sphincter (IAS) defects, and (3) relationship between anal incontinence symptoms and IAS or EAS defect size after repair of an obstetric anal sphincter laceration. Forty-seven vaginally primiparous women underwent obstetric anal sphincter laceration repair. At 8–12 weeks postpartum, anal incontinence symptoms were assessed, and endoanal ultrasound was performed. At 1–2 years postpartum, symptoms were reassesseds. The incidence of anal incontinence symptoms at 8–12 weeks was 43%. The incidence of IAS and EAS defects were 32% and 77%, respectively. IAS defects ≥45 degrees were predictive of symptoms (p = 0.02). After 18 months mean follow-up, 11% reported chronic symptoms. After anal sphincter laceration repair, anal incontinence symptoms occur in 43% of women and remain chronic in 11%. Anal incontinence symptoms are associated with increasing IAS defect size. Poster presentation at the American Urogynecologic Society Annual Meeting, Hollywood, Florida, USA, 27–29 September 2007.     

Anorectal function following low anterior resection

Introduction Rectal function following rectal resection for carcinoma was studied in 43 patients. Methods Sixteen women and 27 men with a median age of 66 years (range 41–79 years) were included. Twenty‐three patients had a diverting ileostomy at the time of resection. Eight patients had a 6‐cm colonic J‐pouch. Ten patients had anastomotic leakage including two patients without diverting ileostomy. One patient had pre‐operative radiation with 25 Gy. The patients were studied at a median 12 months (range 3–30) after rectal resection. Distance from anal verge to the anastomosis was a median 7 cm (range 3–12 cm). Clinical data, anal manometry and rectal compliance were analysed. Results Stool frequency was 3 per day (range 1–10). Twenty‐two (51%) patients were continent, 11 (26%) were incontinent for flatus, and 10 (23%) were incontinent for faeces (three for liquid and seven for solid stool). Fourteen (33%) patients had constipation, two of whom also had incontinence for solid or liquid stool. The level of the anastomosis for patients with postoperative constipation was 5 cm (range 3–12 cm), while it was 7 cm (range 3–10 cm) for nonconstipated patients (NS). Anal manometry was normal. Rectal compliance was lower in patients with incontinence for liquid or solid faeces than in patients with flatus incontinence only (P < 0.01), and rectal volume tolerability was lower in incontinent patients compared with continent patients (P < 0.05). The rectoanal reflex was present in 31 (72%) patients. There was a negative correlation between maximal rectal volume and stool frequency and between level of the anastomosis and degree of incontinence. Age did not affect functional outcome. Conclusion Many patients had a poor functional result following low anterior resection. One in four suffered from incontinence to liquid or solid faeces and one third of the patients experienced constipation. A low level of anastomosis tended to increase stool frequency and carried a higher risk of incontinence. Patients with faecal incontinence tended to have lower rectal compliance and volume tolerability than patients who were continent, while there was no difference in anal pressures.     

Clinical and manometric evaluation of anal sphincter function in patients with rectal prolapse

We studied 27 patients with rectal prolapse (7 men and 20 women). Eight patients were continent, 8 were partially incontinent, and 11 were totally incontinent. Perineal descent and an absent anocutaneous reflex were common findings, implying damage to the external anal sphincter and the pelvic floor muscles. Both partially and totally incontinent patients had significantly lower basal and voluntary contraction pressures compared with those of control subjects, which is in accordance with previous reports on the subject. Our continent patients had normal voluntary contraction pressures, but basal pressures were lower than those of the control subjects (p less than 0.02). This suggests that there may be dysfunction of the internal anal sphincter before the development of clinical symptoms of incontinence. The internal anal sphincter reflex was present in 19 patients (70 percent). It was absent in patients with very little tone of the anal canal. It seems that absence of the internal anal sphincter reflex is not invariably connected with rectal prolapse. The results of this study indicate that rectal prolapse is often associated with dysfunction of the anal sphincters, leading to incontinence.     

Anal sphincter tears in patients with rectal prolapse and faecal incontinence

Objective Faecal incontinence often persists after surgery for rectal prolapse. Multiple mechanisms have been proposed as responsible, however, anal sphincter integrity has only been studied in a handful of cases. This study assesses the incidence of ultrasound detected anal sphincter tears in patients with rectal prolapse and faecal incontinence. Methods Retrospective search of medical records at Flinders Medical Centre over a 7‐year period to identify patients with full thickness rectal prolapse and faecal incontinence who had undergone endosonographical imaging of the anal sphincter complex. Anal manometry and pudendal nerve terminal motor latency studies were also included. Results Twenty‐one patients were identified (1 male, 20 female) of median age 67.5 years. Fifteen (71%) subjects had an abnormality in the anal sphincter complex on endoanal ultrasound. Of these, the defects in 4 (19%) patients were isolated to the internal sphincter, 3 (14%) to the external sphincter and in the remaining 8 (38%) subjects, defects were found in both internal and external sphincters. The degree of sphincteric defect was variable but at least 6 (29%) of the study group had full‐length external sphincter tears. In the 19 patients studied, anal manometry revealed reduced basal and squeeze pressures in the majority. Delayed pudendal nerve terminal motor latency was evident in 9 of 18 patients studied. Conclusion Anal sphincter tears are common in patients presenting with rectal prolapse and faecal incontinence. The faecal incontinence associated with prolapse appears to be multifactorial in aetiology. Anal sphincter defects are likely to contribute to persistent faecal incontinence or recurrence following rectal prolapse. Endoanal ultrasound derived knowledge of anal sphincter injury may guide surgical management in problematic cases.     

Anal manometric parameters: Predictors of outcome following anal sphincter repair?

Controversy exists over the utility of manometry in the management of fecal incontinence. In light of newer methods for the management of fecal incontinence demonstrating favorable results, this study was designed to evaluate manometric parameters relative to functional outcome following overlapping sphincteroplasty. Twenty women, 29 to 84 years of age (mean age 50 years), with severe fecal incontinence and large (≥50%) sphincter defects on ultrasound were studied. All participants underwent anal manometry (mean resting pressure, mean squeeze pressure, anal canal length, compliance), pudendal nerve terminal motor latency (PNTML) testing, and completed the American Society of Colon and Rectal Surgeons fecal incontinence severity index (FISI) survey before and 6 weeks after sphincter repair. Statistical analysis for all data included the Wilcoxon rank-sum test, Mann-Whitney test, and Spearman’s correlation. Significant perioperative improvement was seen in the absolute resting and squeeze pressures and anal canal length. Overlapping sphincteroplasty was also associated with significant improvement in fecal incontinence scores (FISI 36 vs. 16.4; P = 0.0001). Although no single preoperative manometric parameter was able to predict outcome following sphincteroplasty, preoperative mean resting and squeeze pressures as well as anal canal length inversely correlated with the relative changes in these parameters achieved postoperatively. These findings suggest that either the physiologic parameters studied are not predictive of functional outcome or the scoring system used is ineffective in determining function. The perioperative paradoxical changes in resting pressure, squeeze pressure, and anal canal length would support the use of overlapping sphincteroplasty in patients with significant sphincter defects and poor anal tone.     

Importance of evacuatory disturbance in evaluation of faecal incontinence after third degree obstetric tear

OBJECTIVE: To correlate anorectal function including rectal evacuation with anorectal physiology and endoanal ultrasound in women with third degree obstetric anal sphincter injury repaired at the time of delivery. PATIENTS AND METHODS: Forty-four women with repaired third degree tears underwent anorectal physiology, anal ultrasonography and clinical assessment using the St. Marks incontinence score (0-24). Evacuatory disturbance was assessed by questionnaire. RESULTS: There was a significant correlation between disturbed evacuation and incontinence symptoms (P=0.030). There was also a significant correlation between disturbed evacuation and internal anal sphincter (IAS) injury (P=0.026), but there was no correlation with external anal sphincter (EAS) injury. There was a correlation between disturbed evacuation and low resting anal pressure (P=0.013). Although IAS defects were associated with low anal pressure, only the correlation with Maximum Squeeze Pressure reached statistical significance (P=0.018). CONCLUSION: Women with evacuatory disturbance after repaired third degree tears have a greater level of incontinence than those whose emptying is normal. This association is related to internal sphincter injury and reduced anal sphincter pressures.     

Correlation between anal manometry and endosonography in females with faecal incontinence

Objective Female faecal incontinence (FI) is largely because of sphincter injury at childbirth. Sphincter assessment aims to identify surgically correctable defects. We aimed to identify endoanal ultrasonography (EAUS) parameters that correlate with sphincter function. Method One hundred females with FI and 28 healthy asymptomatic females were prospectively assessed. Wexner FI score was recorded and all subjects underwent anorectal manometry and EAUS. Multiple EAUS parameters were assessed and correlated with external (EAS) and internal (IAS) anal sphincter function, determined by maximum squeeze pressure (MSP) and maximum resting pressure (MRP) respectively. Parameters included sphincter quality (echogenicity), thickness, perineal body thickness (PBT) and defect characteristics (angle, length). Results are expressed as medians and interquartile range (IQR). Results Median Wexner score was 14 (12–17). Maximum EAS thickness significantly correlated with MSP (P = 0.019). EAS defects were detected in 84 patients and seven controls (P < 0.0001). Full‐length EAS defects were only detected in FI group and had significantly lower MSP [MSP mmHg: full length 85 (65–103) vs partial length 119 (75–155), P = 0.006]. FI patients were more likely to have a mixed echogenicity of EAS compared with controls. EAS ring quality, PBT and defect angle were not significant. IAS quality was significantly associated with MRP [MRP mmHg: uniform 62 (43–82) vs mixed 47 (30.5–57.5), P = 0.002]. Conclusion Certain EAUS parameters can be predictive of anal sphincter function. These include the presence of an EAS defect and its length, EAS maximum thickness, IAS ring quality. Integration of these parameters can give better EAUS correlation with manometry for FI evaluation.     

Is a morphologically intact anal sphincter necessary for success with sacral nerve modulation in patients with faecal incontinence?

Objective Sacral nerve modulation (SNM) for the treatment of faecal incontinence was originally performed in patients with an intact anal sphincter or after repair of a sphincter defect. There is evidence that SNM can be performed in patients with faecal incontinence and an anal sphincter defect. Method Two groups of patients were analysed retrospectively to determine whether SNM is as effective in patients with faecal incontinence associated with an anal sphincter defect as in those with a morphologically intact anal sphincter following anal repair (AR). Patients in group A had had an AR resulting in an intact anal sphincter ring. Group B included patients with a sphincter defect which was not primarily repaired. Both groups underwent SNM. All patients had undergone a test stimulation percutaneous nerve evaluation (PNE) followed by a subchronic test over 3 weeks. If the PNE was successful, a permanent SNM electrode was implanted. Follow‐up visits for the successfully permanent implanted patients were scheduled at 1, 3, 6 and 12 months and annually thereafter. Results Group A consisted of 20 (19 women) patients. Eighteen (90%) had a positive subchronic test stimulation. Twelve patients had a successful SNM implant during middle‐term follow‐up. Group B consisted of 20 women. The size of the defect in the anal sphincter varied between 17% and 33% of the anal circumference. Fourteen (70%) had a positive subchronic test stimulation. Twelve patients had a successful SNM implant during middle‐term follow‐up. In both groups, the mean number of incontinence episodes decreased significantly with SNM (test vs baseline: P = 0.0001, P = 0.0002). There was no significant difference in resting and squeeze pressures during SNM in group A, but in group B squeeze pressure had increased significantly at 24 months. Comparison of patient characteristics and outcome between groups A and B revealed no statistical differences. Conclusion A morphologically intact anal sphincter is not a prerequisite for success in the treatment of faecal incontinence with SNM. An anal sphincter defect of <33% of the circumference can be effectively treated primarily with SNM without repair.     

Can anal manometry predict anal incontinence after fistulectomy in males?

BACKGROUND: Disordered continence is frequently reported after operations for anal fistulae and pre-operative anorectal physiology may be carried out prior to surgery to improve functional outcome. Elderly patients and multiparous females are at higher risk for incontinence, whereas males under 60 have stronger sphincters. The aim of this study was to investigate the predictive role of anal manometry and the causes of postoperative soiling and its effect on the quality of life in males with intact sphincters undergoing excision of either trans or supra sphincteric fistulae. METHODS: Thirty-eight patients (median age 47 years) were analysed retrospectively. None had previous anal surgery and all were fully continent. Five had Crohn's disease. Anal pressures and rectal sensation were evaluated prior to fistulectomy by means of anal manometry in all cases and after surgery in those who had postoperative incontinence. A cutting seton was used in 17 patients, a rectal advancement flap in 15 and a double rectal-cutaneous flap in six. None had a lay-open. The intersphincteric plane was explored and drained in all cases. A previously described incontinence grading and score was used to assess postoperative soiling. The median follow-up was 22 (range 5-89) months. The patients with postoperative anal incontinence were evaluated with the Gastrointestinal quality of Life Index Questionnaire (0:poor, 4:good) at a median follow-up of 49 months. RESULTS: Twenty-nine (76%) patients were continent after surgery, whereas 9 (24%) complained of some degree of anal incontinence (minor in 4, severe in 1, the 1-6 incontinence score being 3.7 +/- 1.3 (mean +/- s.d.m.). Their Quality of life score was 3.8 +/- 0.5 (mean +/- sdm). None of them had Crohn's disease, five had frequent diarrhoea, four had a reintervention for either anal fissure or recurrent fistula (two), three had a postseton anal deformity. No difference was found between continent and incontinent patients as far as pre-operative anal pressures were concerned, but the maximum rectal volume threshold was significantly higher in incontinent patients, 165 +/- 67 vs. 123 +/- 49 ml of air (P = 0.04). CONCLUSIONS: Sphincter division, diarrhoea and anal deformity may cause soiling after fistulectomy in males and it does not severely affect quality of life. Surgery rather than manometry may predict it and rectal sensation may play a role which needs further investigation.     

Faecal incontinence after lateral internal sphincterotomy is often associated with coexisting occult sphincter defects: a study using endoanal ultrasonography

Background : Troublesome faecal incontinence following a lateral internal sphincterotomy (LIS) is often attributed to faulty surgical techniques: division of excessive amount of internal sphincter or inadvertent injury to the external sphincter. The aim of the present paper was to assess the anatomic and physiological factors that may contribute to faecal incontinence following a technically satisfactory lateral internal sphincterotomy by a group of colorectal specialists. Methods : Fourteen patients (nine women, five men; median age: 38 years; range: 23–52 years) who developed troublesome postoperative faecal incontinence were evaluated by clinical assessment, endoanal ultrasonography and anorectal physiological studies (manometry, pudendal nerve terminal motor latency) by two independent observers. The Cleveland Clinic continence score (0–20; 0, perfect continence; 20, complete incontinence) was used to quantify the severity of faecal incontinence. Fourteen continent subjects after a LIS (nine female patients, five male patients; median age: 36 years; range: 20–44 years) were also evaluated as ‘continent’ controls (continence score ≤ 4). Results : In the incontinent group, the median postoperative Cleveland Clinic continence score was 9 (range: 6–13) compared with a preoperative score of 1 (range: 0–3). On assessment by endoanal ultrasonography the site of the internal sphincterotomy was clearly identified. There were additional coexisting defects, on endoanal ultrasonography, of the external anal sphincter in seven female patients, of the internal sphincter in two female and two male patients; and a defect of both the external and internal sphincters in a male patient who had had a prior fistulotomy. The pudendal nerve terminal motor latency (PNTML) was prolonged in two female patients on the side contralateral to the lateral internal sphincterotomy. In two of five male patients there was no evidence of any occult sphincter injuries. In the continent controls a defect of the distal portion of the external sphincter was noted in one female patient. None of the patients had a prolonged PNTML. The maximum voluntary contraction was significantly lower in the female subjects than in the female continent controls (92 mmHg vs 140 mmHg; P < 0.05), while the resting anal canal pressures and length of the high pressure zone were similar between the study subjects and the continent controls. Conclusion : Troublesome faecal incontinence after a satisfactorily performed lateral internal sphincterotomy is often associated with coexisting occult sphincter defects.     

Design and evaluation of puborectalis-like artificial anal sphincter that replicates rectal perception

While fecal incontinence (FI) is not fatal, it can dramatically decrease the patient’s quality of life. An artificial anal sphincter (AAS) is an implantable device that treats FI by replacing a diseased or damaged anal sphincter, thus allowing the patient’s continence to be maintained. Here, we report a novel implantable puborectalis-like artificial anal sphincter (PAAS) that replicates rectal perception and has a low risk of ischemia necrosis. Using the pressure sensors embedded in the PAAS, the relationship between the mass of feces and the pressure was determined, and a feces mass estimation model was developed based on in vitro studies. Rectal perception is provided through the real-time monitoring of rectal feces, and the feeling of defecation is quantified based on a comparison between the feces mass and a preset threshold mass. In vivo studies were performed for validation, and the accuracy of the model was determined to be as high as 90%. The performance of the PAAS in the real-time monitoring of rectal feces and its in vivo biocompatibility were also evaluated. The device should further the functionality of existing AAS systems while improving their biosafety and thus expand the applicability of implantable AAS systems in the treatment of FI.     

Three‐dimensional endoanal ultrasonography of external anal sphincter defects in patients with faecal incontinence: correlation with symptoms and manometry

Aim Anal sphincter anatomy on two‐dimensional endoanal ‐ultrasonography (EUS) does not always correlate with the clinical data. The purpose of this study was to determine whether three‐dimensional (3D) measurements yield a better correlation. Method The study group included consecutive patients who underwent 3D EUS for faecal incontinence over a 2‐year period. The medical charts were reviewed for Cleveland Clinic Foundation Fecal Incontinence (CCF‐FI) score and manometric pressures. Endoanal ultrasonographic images were reviewed for the presence of an external anal sphincter (EAS) defect and its extent, as determined by the radial angle, length in the sagittal plane and percentage volume deficit. Correlational analyses were performed between the clinical and imaging data. Results Sixty‐one patients of median age 53 years (range 15–82) were evaluated. Thirty‐two patients had either a complete (17) or partial (15) EAS defect, and 29 patients had an intact sphincter. The CCF‐FI scores were similar in patients with and without an EAS defect (12.5 ± 5.6 and 11.4 ± 5.5, respectively). The intact‐sphincter group had a significantly greater EAS length (3 ± 0.4 vs 2 ± 0.62 cm, P = 0.02) and higher mean maximal squeeze pressure (MMSP; 99.7 ± 52.6 vs 66.9 ± 52.9 mmHg, P = 0.009). There were no statistically significant correlations between MMSP, CCF‐FI score and EAS status on 3D EUS. Mean percentage volume of the defect was similar in patients with complete and partial tears (14.5 ± 5.5 and 17.5 ± 7.2%, P = 0.25) and showed no correlation with physiological tests or symptom scores. Conclusion Improvements in external anal sphincter imaging have not yielded a better association with the clinical findings. The lack of clinical differences between patients with different EAS tears may reflect their similar volumetric defects.     

Imbrication of the external anal sphincter may yield similar functional results as overlapping repair in selected patients

Objective Overlapping external anal sphincter repair is the preferred procedure for incontinent patients with functional yet anatomically disrupted anterior external anal sphincter. When incomplete disruption, thinning or technically difficult mobilization of the external anal sphincter occurs, imbrication without division may be the more feasible surgical option. The aim of the study was to assess retrospectively the indications for external anal sphincter imbrication in patients who underwent either overlapping external anal sphincter repair or external anal sphincter imbrication, and to compare the success rates. Method Patients who had external anal sphincter repair and follow up of at least 3 months were studied. Fecal incontinence was measured using the validated Wexner fecal Incontinence Scoring system (0 = perfect continence, 20 = complete incontinence); postoperative scores 0–10 were interpreted as successful, and scores of 11–20 as failures. Results A total of 131 females who had anal sphincter repair between 1988 and 2000 were analysed. One hundred and twenty‐one patients had overlapping external anal sphincter repair (group I), and 10 had external anal sphincter imbrication (group II). Indications for external anal sphincter imbrication were attenuation of the external anal sphincter without overt defect (n = 5), partial disruption of external anal sphincter with muscle fibres bridging the scar (n = 2), thick bulk of scar between the muscle edges (n = 2), and wide lateral retraction of the muscle edges (n = 1). There were no statistically significant differences between the groups relative to preoperative incontinence score (16.5 vs 16.5, P = 0.99), pudendal nerve terminal motor latency assessment (left 9.6%vs 0.0%, P = 0.19; right 13.4%vs 11.1%, P = 0.84), and extent of electromyography pathology (61%vs 47%, P = 0.30). The patients in group I were younger than those in group II (mean age 50.8 years vs. 61.7 years, respectively; P = 0.052) and the length of follow‐up was significantly longer (32.3 months vs 14.3 months, respectively; P < 0.0001). Both procedures had similar success rates (59.5%vs 60%; P = 0.98). Conclusion Imbrication of the external anal sphincter may yield similar results as overlapping external anal sphincter repair in patients with incomplete external anal sphincter disruptions, external anal sphincter attenuation, and in patients presenting with wide lateral retraction of the muscle edges.     

Anterior anal fissures are associated with occult sphincter injury and abnormal sphincter function

Objective The pathogenesis of chronic anal fissure (CAF) remains incompletely understood but most are associated with a high resting anal pressure and reduced perfusion at the fissure site. To date, no major distinction has been made between anterior and posterior anal fissures and their aetiology and treatment. We compared anterior and posterior fissures in patients who have failed to respond to medical treatment with respect to their underlying aetiology, anal canal pressures and sphincter muscle integrity. Method Seventy consecutive patients (54 female:16 male) with a symptomatic CAF and 39 normal controls (19 female:20 male) without evidence of significant ano‐rectal pathology were prospectively assessed by manometry and anal endosonography. Results Anterior anal fissures were identified in a younger age group [33 years (IQR 26–37) vs 41 years (IQR 36–52)] and predominantly in women. Anterior fissure patients were significantly more likely to have underlying external anal sphincter defects compared with posterior fissures [OR 10.9 (95% CI 3.4–35.4)]. Maximum resting pressure was not significantly elevated for anterior fissures compared with controls (P = 0.316) but was significantly elevated in posterior fissures (P = 0.005). The maximum squeeze pressure was significantly lower in the anterior fissure group [167 cmH₂O (IQR 126–196) vs 205 cmH₂O (IQR 174–262), P = 0.004]. A history of obstetric trauma was significantly associated with anterior fissure location [OR 13.9 (95% CI 3.4–55.7)]. Conclusions Anterior anal fissures are associated with occult external anal sphincter injury and impaired external anal sphincter function compared with posterior fissures. These findings have implications for treatment, especially if a definitive procedure, such as lateral internal sphincterotomy, is considered.     

Prospective study of the diagnostic evaluation of faecal incontinence and leakage in male patients

OBJECTIVE: Male faecal incontinence (FI) has received little attention. No consistent pathophysiological abnormality has been identified in those studies that have specifically assessed male patients with FI or faecal leakage (FL). This study was designed to re-examine the different theories relating to the pathophysiology of male incontinence and to assess if manometric and ultrasound assessment yields clinically relevant information that directs patient care. METHOD: This was a prospective study of all men referred to a Coloproctology clinic with incontinence. The Wexner Incontinence score was used to assess severity of symptoms. Specific investigations included anal manometry, rectal sensation and endo-anal ultrasound (EAUS). Results were compared with a group of 20 normal male controls. RESULTS: A total of 59 symptomatic male patients were investigated (36 FI, 23 FL). FL and control groups had similar maximum resting (MRP) and maximum squeeze pressure (MSP). The incontinence group had a significantly lower MRP & MSP compared with controls [MRP: FI 58 (42-75.5) vs control 85 (72-104)] (P < 0.0001), [MSP: FI 167 (125-215) vs control 248 (192-302)] (P < 0.0001). There was no significant difference in rectal sensation between the groups and the defecation index was also similar. EAUS detected only one external anal sphincter defect amongst the 23 male patients with FL. One external sphincter defect and three internal sphincter defects were identified amongst the 36 patients with incontinence. Of these five patients with sphincter defects, four had previously undergone anorectal surgery. [Results expressed as median (interquartile range): manometry expressed as mmHg]. CONCLUSION: Male patients presenting with faecal incontinence frequently show impaired sphincter function which may be associated with sphincter defects. In contrast, those presenting predominantly with FL have no morphological or physiological changes that might account for their symptoms. Investigating such patients with anorectal physiology and EAUS is usually unhelpful and can be omitted.     

Selecting patients with faecal incontinence for anal sphincter surgery: the influence of irritable bowel syndrome

Aim This was a prospective study to determine the prevalence of irritable bowel syndrome (IBS) in patients with faecal incontinence and to investigate the association of IBS positivity with sphincter dysfunction. Method Patients with faecal incontinence were referred for physiological assessment and further management. Those with an acute obstetric injury, rectal prolapse or previous anorectal surgery were excluded. One hundred and seventy‐seven women were studied. Symptom questionnaires were used prospectively to identify IBS positivity using Rome 11 criteria and the Cleveland Clinic incontinence score. Results The prevalence of IBS was 44%. IBS patients had higher incontinence scores than non‐IBS patients (11.0 vs 9.0, P < 0.01). A normal or high maximum resting anal pressure in an incontinent woman increased the chance of her having IBS by a factor of 2.6. Conclusion The prevalence of IBS positivity in patients presenting with faecal incontinence was high. A normal or high anal resting pressure and a high incontinence score should raise the suspicion of IBS.     

Predictive factors for faecal incontinence after third or fourth degree obstetric tears: a clinico-physiologic study

Objective  This is a prospective study to review the natural history of anorectal dysfunction after primary repair for third or fourth degree obstetric tear and to identify the predictive factors for significant faecal incontinence.
Method  From January 2003 to December 2005, 121 consecutive women (mean age 29.9 ± 4.7) who sustained third or fourth degree obstetric tears were assessed. All had primary repair by obstetricians. They were assessed using anorectal physiology testing and endoanal ultrasound. Short-term (3-month postpartum) and medium-term (mean 18.8 ± 7.7 months) Wexner's continence scores were obtained.
Results  Among the 121 women, seven were excluded because of incomplete follow-up. At short-term assessment, 25 out of 114 women were incontinent. One of them underwent another sphincter repair for significant faecal incontinence. Twenty-one and three patients respectively, had mild (Wexner's score 1–4) and moderate (Wexner's score 5–8) symptoms. At medium-term assessment, 24 patients remained incontinent; of these, 20 had mild symptoms (Wexner's score 1–4) and four had moderate incontinence (Wexner's score 5–8). The parity ( P  =   0.04), degree of obstetric tear ( P  =   0.036) and short-term Wexner's scores at 3 months postpartum ( P  <   0.0001) were significantly related to the change in Wexner's scores at medium-term assessment. However, the short-term Wexner's score was the only identifiable predictive factor for significant faecal incontinence.
Conclusion  Most women suffering from third or fourth degree obstetric tear were continent or mildly incontinent. Poor Wexner's score at short-term assessment at 3 months postpartum was predictive of faecal incontinence in the medium-term.     

Maximum anal sphincter strength measured by the solid sphere test and anal pressure profiles.

OBJECTIVE--To evaluate two methods of quantifying external anal sphincter function. DESIGN--Open study. SETTING--Helsingborg Hospital, Sweden. SUBJECTS--73 patients (63 women and 10 men), of whom 25 were incontinent of gas and liquid or solid stool. INTERVENTIONS--Anal pressure profiles and the "solid sphere" test. OUTCOME MEASURE--Correlation between results of tests and presence of incontinence. RESULTS--Continent patients were younger than incontinent ones. The correlation between the maximum force the patient could retain and the maximum anal squeeze pressure was good (r = 0.67, p < 0.001). Younger continent patients (n = 48) and significantly higher pressures than incontinent patients (n = 25), but the range and overlap were wide. The reproducibility of both methods was good. CONCLUSIONS--Although the solid sphere test is easier and quicker to do, anal pressure profiles yield more information that is important in the evaluation of incontinence.