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.     

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.     

A cost-effectiveness analysis of delayed sphincteroplasty for anal sphincter injury

Objective  Anal-sphincter injury may result in faecal incontinence. Sphincteroplasty is usually performed as a primary (immediate) procedure. Delayed sphincteroplasty (DS) can be performed if there is significant trauma or soiling, if the primary procedure has failed, and if the injury was not recognized initially. This study aimed to determine the cost to patient and health service in the event a DS is performed.
Method  Patients with anal-sphincter-injury who underwent primary sphincteroplasty (PS)/DS were identified from the published literature (primary, n  = 103; delayed, n  = 777) using Medline, Embase, Ovid and Cochrane databases for studies published between 1976 and 2006. Studies included described at least one of the measured outcomes – probability of functional success/failure and quality of life (QOL). An economic model was constructed and decision analysis performed using a decision tree based on a Markov process. Main outcomes were quality-adjusted-life-years (QALYs) gained from each strategy, costs incurred and incremental cost-effectiveness ratio (ICER) over a 10- and 15-year time horizon.
Results  Over 10 years, primary sphincteroplasty (PS) produced a gain of 5.72 QALYs for an estimated £2750, giving an ICER of £487 per QALY. DS produced a gain of 3.73 QALYs for a cost of £2667, giving an ICER of £719 per QALY. Both procedures fell below the £10 000 per QALY willingness-to-pay threshold, but PS produced the highest QALYs. Both procedures performed poorly beyond the 10-year mark.
Conclusion  If DS has to be performed, the resultant cost is greater with concurrently lower QALYs gained. Successful PS substantially improves QOL and reduces overall cost-of-treatment.     

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.     

Assessment of sonographic quality of anal sphincter muscles in patients with faecal incontinence

Objective  The main application of endoanal ultrasonography (US) in evaluation of faecal incontinence is to identify surgically correctable sphincter defects. The aim of our study was to determine whether qualitative changes in echogenicity and in uniformity of internal (IAS) and external (EAS) anal sphincter muscles detected on endoanal US correlate with other anal laboratory tests and modified Wexner faecal incontinence functional score.
Method  Records on 99 patients having complete information on anorectal manometry, faecal incontinence scoring and available endoanal US imaging of the anal sphincters were included in statistical analysis. Anatomic appearance and changes in echogenicity of the anal sphincter muscles were recorded according to the proposed scoring system. Endoanal US defect and quality component scores for IAS and EAS as well as the total score were correlated with anal laboratory tests and incontinence score using Spearman's correlations test.
Results  There was a trend for correlation between IAS quality score and incontinence score ( P  = 0.06), but no correlation for IAS defect score. EAS defect score had a significant negative correlation with maximum squeeze pressure (MSP) ( P  = 0.031). Distal EAS quality score had a significant correlation with incontinence score ( P  = 0.002). EAS total score correlated with MSP ( P  = 0.02) and incontinence score ( P  = 0.006). Endoanal US total score was significantly correlated with incontinence score ( P  = 0.006), maximal resting (MRP) ( P  = 0.035) and MSP ( P  = 0.045) and high pressure anal canal zone length ( P  = 0.03).
Conclusion  Sonographic morphology of anal sphincter muscles correlates with anal laboratory tests and functional incontinence score. Qualitative ultrasound scoring instrument may improve evaluation of patients with faecal incontinence.     

Artificial bowel sphincter in severe anal incontinence

OBJECTIVE: The artificial anal sphincter has been suggested as an alternative in the treatment of severe anal incontinence when conventional surgical methods are not possible or have failed. Experience in this procedure is still limited and the results have not yet been sufficiently established. The aim of this study is to evaluate the efficacy of the ACTICON (American Medical Systems, Minneapolis, MN) on patients operated upon in our Unit. PATIENTS AND METHOD: In this prospective study an ACTICON sphincter was implanted in 10 patients (8 women) with an average age of 56 years and with an average period of severe anal incontinence of 151 months. The origin of incontinence was obstetric injury (n: 4), neuropathy (n: 3) and sphincteral injury from previous anal surgery (n: 3). The degree of continence was measured using the Fecal Incontinence Scoring System (FISS) and the pre- and postoperative anal manometric parameters at 6-month intervals. The average follow-up time for the efficacy of the implanted system was 29 months. RESULTS: A total of 6 patients [60%] displayed complications in the immediate postoperative period: subaponeurotic reimplantation of the connecting tubes was necessary after infection of the abdominal wound (n:1); superficial dehiscence of the perianal wound (n: 2), infection of the perianal wound (n: 1) and perianal haematoma (n: 2) that were resolved by conservative treatment. For 3 patients [30%] the system was explanted, definitively in one and in 2 of them reimplanted successfully. At the end of the follow-up period, 9 patients [90%] still have an activated artificial sphincter. The score on the Fecal Incontinence System decreased significantly after the system was activated (P < 0.0001) and the pressure with the cuff closed was significantly higher than pre-operative anal pressure (P < 0.0001). All the patients are now continent for solid stool, 56% have occasional involuntary losses of gases and 33% occasionally have involuntary losses of gases and liquid stool. Only 2 patients [22%] have complete continence. CONCLUSIONS: Our findings indicate that the ACTICON artificial anal sphincter is well tolerated and can be an effective alternative in the treatment of severe anal incontinence. Although complete continence is only achieved in a low percentage of cases, for the rest of the patients the ACTICON neosphincter reduces the symptoms considerably.     

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.     

Fatigue rate of the external anal sphincter

Aim Studies of skeletal muscle show that fatigue rate corresponds to the proportion of fast‐twitch and slow‐twitch fibres that are present in the muscle. Limited work has been done on the fatigue rate of the external anal sphincter. We have prospectively studied fatigability of the external anal sphincter in women with faecal incontinence and women with normal bowel control. Method Anorectal manometry was measured by a station‐pull technique using a water‐filled microballoon. Fatigue rate was calculated from anal pressure measurements taken every 0.1 s over a 20‐s squeeze. Results Women with faecal incontinence (n = 88, median ?12 cmH₂O/min) were less susceptible to fatigue than women with normal bowel control (n = 36, median ?43 cmH₂O/min) (P < 0.01). The external anal sphincter was less susceptible to fatigue with increasing age (P < 0.01, r = 0.499). In women with normal bowel control and in women with faecal incontinence fatigue rate was negatively correlated with maximum squeeze pressure (P < 0.01, r = ?0.287; P < 0.01, r = ?0.579). Conclusion The external anal sphincter was less susceptible to fatigue with increasing age. Women with faecal incontinence have a weaker but more fatigue‐resistant external anal sphincter. This might correspond to a higher proportion of slow‐twitch muscle fibres. Histological studies are needed to examine this hypothesis.     

Sacral neuromodulation for combined faecal and urinary incontinence following obstetric anal sphincter injury

Aim

The aim of this study was to investigate the efficacy of sacral neuromodulation (SNM) in the treatment of faecal incontinence and concomitant urinary incontinence in women with a history of obstetric anal sphincter injury (OASIS).

Method

In this prospective study, consecutive women with faecal incontinence following OASIS accepted for SNM were screened for concomitant urinary incontinence. The primary outcome was the change in urinary incontinence score on the International Consultation on Incontinence Questionnaire for Urinary Incontinence, Short Form (ICIQ‐UI‐SF), between baseline and 12 months. Secondary outcomes included the change in St Mark's score, sexual function and quality of life, change in grade of urinary incontinence and disappearance of urgency.

Results

From March 2012 to September 2014, 39 women with combined faecal incontinence and urinary incontinence received SNM. Thirty‐seven women were available for analysis after 12 months. The mean reduction in the ICIQ‐UI‐SF score between the baseline and 12 months was 5.8 (95% CI 3.7–8.0, P < 0.001). ICIQ‐UI‐SF was reduced in 29 (78%) women, urinary incontinence resolved in 13/37 (35%, 95% CI 20%–50%) patients, and urgency disappeared in 14/33 (42%, 95% CI 26%–59%). The mean reduction in the St Mark's score was 10.6 (95% CI 8.6–12.7, P < 0.001). Disease‐specific quality of life, Euroqual 5‐dimension visual analogue scale (EQ‐5D VAS) and several areas of sexual function changed significantly for the better.

Conclusion

More than three‐quarters of the women with combined faecal and urinary incontinence following OASIS reported a successful outcome with reduction in ICIQ‐UI‐SF at 12 months after SNM.     

Asymmetric sphincter innervation is associated with fecal incontinence after anal sphincter trauma during childbirth

AIMS: Functional asymmetry of pelvic floor innervation has been shown to exist in healthy subjects, and has been proposed to be a predictor of increased risk for fecal incontinence in case of trauma. However, this remains to be shown for different clinical conditions such as traumatic childbirth. METHODS: A conventional surface EMG system was used to assess the innervation of the external anal sphincter. A symmetry index was used to define the relative EMG amplitude asymmetry of the external anal sphincter between 0 (symmetric) and 1 (asymmetric). Three cohorts were studied: 40 nulliparous women in the third trimester (Study 1), 15 primiparous women within 6 months following vaginal delivery without clinically apparent anal sphincter trauma (Study 2), and 50 women after childbirth-related third or fourth degree perineal tear 6-12 months postpartum (Study 3). Furthermore, all women underwent conventional anorectal manometry. RESULTS: Sixteen or forty nulliparous women reported signs of fecal incontinence; however, relative asymmetry was not correlated to symptom severity (P = 0.345), and not to manometric measures (Study 1). In Study 2, Women who had suffered clinically apparent anal sphincter trauma (P = 0.07) tended to have a stronger association between incontinence and asymmetry. In Study 3, 19/50 women reported moderate to severe incontinence. Asymmetry and symptom severity were significantly correlated (P < 0.001). Patients with incontinence had a significantly higher asymmetry score than their continent counterparts. CONCLUSION: Functional asymmetry of anal sphincter innervation is significantly associated with incontinence symptoms, but only after childbirth-related sphincter injuries and therefore, should be regarded as an additional risk factor.     

Anorectal function evaluation and predictive factors for faecal incontinence in 600 patients

Aim Anorectal function was assessed in patients with and without faecal incontinence (FI) . Risk factors predictive for FI were determined. Method Between 2003 and 2009, all consecutive patients referred were assessed by questionnaire, anorectal manometry and anal endosonography. Predictive factors were identified and used to develop a statistical model to predict FI. Results Of 600 patients (519 women), 285 (48%) were faecally incontinent. In comparison with continent women, incontinent women (mean Vaizey score 15.4), were older, had more liquid stools, more deliveries, more urinary incontinence, lower anal pressures, shorter sphincter length, smaller rectal capacity and more sphincter defects. Incontinent men (mean Vaizey score 15.3) were older and had lower anal pressures. Incontinent and continent patients showed an overlap in test results. Predictors in women were age, stool consistency, anal pressures, rectal capacity, and internal and external sphincter defects. The area under the ROC‐curve was 0.84 (P < 0.001; 95% confidence interval, 0.80–0.87). Using a cut off point of 0.4, FI was predicted with sensitivity, specificity, positive and negative predictive values of 86%, 68%, 74% and 82%, respectively. The model was studied in five women with a temporary stoma and was accurate in predicting FI after stoma closure. Conclusion Incontinent patients have lower pressures, smaller rectal capacity and more sphincter defects than controls, but show a large overlap. Our model shows a relatively high sensitivity and negative predictive value for predicting FI in women. The model seems promising in the patients studied with a temporary stoma.     

Sacral nerve stimulation in faecal incontinence associated with an anal sphincter lesion: a systematic review

Aim The long‐term results of sphincteroplasty for faecal incontinence due to an anal sphincter lesion have been disappointing. Initially sacral nerve stimulation was used only in faecal incontinence of neurogenic origin but subsequently the indications have been extended to other conditions. The aim of this review was to evaluate sacral nerve stimulation for incontinence in the presence of a sphincter defect. Method The MEDLINE, Embase and Cochrane Library databases for the period between 1995 and 2011 were searched for studies in English, with no limitations concerning the study size or the length of follow‐up. The major endpoints were clinical efficacy, changes in anorectal manometry and quality of life. Results Ten reports (119 patients) satisfied the inclusion criteria. The quality of the studies was low (nine were retrospective, one was prospective). All reported a lesion of the external anal and/or internal anal sphincter on endoanal ultrasound. A definitive implant was performed on 106 (89%) of the 119 patients who underwent a peripheral nerve evaluation test. The weighted average number of incontinent episodes per week decreased from 12.1 to 2.3, the weighted average Cleveland Clinic Score decreased from 16.5 to 3.8, and the ability to defer defaecation, when evaluated, increased significantly. The features at anorectal manometry did not change. The quality of life improved significantly in almost all studies. Conclusion Sacral nerve stimulation could be a therapeutic option for faecal incontinence in patients with an anal sphincter lesion. However, the quality of the published studies is low. A randomized clinical trial comparing sacral nerve stimulation with other classical surgical procedures at long‐term follow‐up, although beset with difficulties, should be conducted.     

Neoadjuvant radiochemotherapy for patients with locally advanced rectal cancer leads to impairment of the anal sphincter

Neoadjuvant radiochemotherapy (RCTx) has become an acceptable therapy for patients with locally advanced rectal cancer. However, little is known about the effect of the RCTx on the function of the anal sphincter. Forty-one consecutive patients with locally advanced rectal cancer (cT3, N+) underwent neoadjuvant RCTx with subsequent resection. All patients were examined clinically and by anal manometry for their anal sphincter function. A multichannel water-perfused catheter system was used, and resting pressure, maximum squeeze pressure, and length of the anal high-pressure zone were determined prior to the neoadjuvant therapy and before the operation. The length of the high-pressure zone did not change after the neoadjuvant therapy. However, resting and maximum squeeze pressure decreased significantly after preoperative RCTx. This effect was more pronounced for the resting pressure rather than the maximum squeeze pressure, indicating that the internal sphincter is primarily affected. These results correlated with the clinical data showing an impaired continence status in patients treated with neoadjuvant therapy. Neoadjuvant RCTx leads to impairment of the anal sphincter predominantly in the internal sphincter. This effect may enhance the surgical impairment of continence after curative resection.     

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.     

The relationship between external anal and external urethral sphincter activity in continent women

The relationship between the external anal sphincter and the periurethral sphincter muscles is an unresolved issue. Recordings of the external anal sphincter (EAS) are commonly used to indicate the responses of the urethral sphincter during urodynamic evaluations and in biofeedback procedures for the treatment of urinary incontinence. This study examined the validity of using anal sphincter training to teach control of the external urethral sphincter. Subjects were 5 continent women, aged 37–51 years, who reported being free of all urologic symptoms. Using visual biofeedback of anal sphincter pressure, subjects were trained to voluntarily contract the sphincter to four amplitudes: 5, 10, 15, and 20 mmHg (6.8, 13.6, 20.4, and 27.2 cmH₂O). Then they were guided through a series of controlled anal sphincter contractions, while the response of the urethral sphincter was measured using surface electrodes embedded in a Foley catheter. At each of four bladder volumes, subjects performed 16 contractions (four contractions at each of the four amplitudes). The order of contractions was counterbalanced, using a Latin square design. The results show a strong, statistically significant, monotonic relationship between the magnitude of anal sphincter contraction (pressure) and the level of urethral sphincter electromyographic (EMG) activity. The results support the use of the external anal sphincter as an indicator of urethral sphincter activity for the purpose of conducting biofeedback in the treatment of urinary incontinence.