Anal Incontinence After Obstetric Third- /Fourth-Degree Laceration. One-Year Follow-up After Pelvic Floor Exercises

The study was a 1-year follow-up of 48 women with obstetric third- /fourth-degree perineal laceration. After primary surgical repair the symptomatic patients were treated with pelvic floor exercises with or without transanal electrical stimulation. Various methods for assessing anal sphincter function were also evaluated. One month postpartum 10 women (21%) complained of anal incontinence, 8 for flatus only; 1 patient was reoperated on. After 1 year none complained of fecal incontinence, and 3 (7%) complained of flatus incontinence. We found relatively few women with anal incontinence after third- /fourth-degree laceration. The pelvic floor training program was effective, but electrical stimulation was abandoned because of anal pain. Grade IIIb lesion, dilution of the sphincter at anal ultrasonography, and sphincter weakness at palpation were significantly related to symptoms of anal incontinence. For routine follow-up after third- /fourth-degree laceration, palpation of the anal sphincter and pelvic floor seems sufficient as first-line assessment.     

Treatment of anal incontinence by an implantable prosthetic anal sphincter.

Twelve patients with anal incontinence due to neurologic disease or failure of previous incontinence surgery underwent implantation of an artificial anal sphincter. The system used was a modification of the AMS 800 artificial urinary sphincter. In two patients, infection necessitated removal of the system, and in four patients, eight revisional procedures had to be performed because of mechanical failure. After various modifications of the system, especially reinforcement of the closing mechanism of the cuff, only one case of mechanical failure has occurred. Erosion through the anal canal did not occur. Among 10 patients with the system in function for more than 6 months, the result was considered excellent in 5, with only occasional leakage of flatus, good in 3, who occasionally leaked liquid feces and flatus, and acceptable in 2, in whom the cuff obstructed defecation. It is concluded that implantation of an artificial anal sphincter is a valid alternative to permanant colostomy in patients with anal incontinence due to neurologic disorders and in patients in whom other types of incontinence surgery have failed.     

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.     

肛门直肠畸形术后排粪失禁患儿盆腔磁共振成像表现及其临床意义

目的通过肛门直肠畸形术后排粪失禁患儿的盆腔MRI表现,了解盆底肌的形态,直肠、肛管的形态和位置,以及脊髓和骶骨的发育,为分析排粪失禁的原因及制订治疗方案提供客观依据。方法回顾性分析2009年9月至2011年12月间山东大学第二医院收治的34例肛门直肠畸形术后排粪失禁患儿的临床和影像资料,其中男2l例,女13例,年龄3,14岁。应用1．5TMR扫描仪,常规行轴位、冠状位及矢状位扫描,观察肛门括约肌、耻骨直肠肌和提肛肌、直肠、肛管的形态,以及脊髓、骶骨的发育情况。结果MRI检查提示：肛门外括约肌发育不良18例,耻骨直肠肌发育不良23例,肛提肌发育不良27例;直肠位置异常6例,直肠扩张12例,肛直角增大11例;肛管周围脂肪组织5例;合并神经管闭合不全2例,Currarino综合征2例,骶骨发育不全11例,直肠尿道瘘2例。以上影像学结果均经临床最终证实。结论MRI可清楚显示肛门外括约肌、耻骨直肠肌和肛提肌的形态,以及直肠和肛管的形态和位置,同时还可显示脊髓和骶骨的发育情况,是评价肛门直肠畸形术后排粪失禁患儿非常有价值的检查方法。     

Mayo Clinic experience with use of the AMS800 artificial urinary sphincter for urinary incontinence following radical prostatectomy

The model AMS800 artificial urinary sphincter was implanted in 117 patients with urinary incontinence resulting from radical prostatectomy. The indication for implantation was total incontinence in 107 patients and stress incontinence in 10. All patients had bulbous urethral cuff insertion and 20 had previous pelvic irradiation. Followup questionnaire indicated a 90% significantly improved continence rate and a 90% satisfaction rate among patients. There were 64 surgical revisions required in 37 patients: inadequate cuff compression in 21 (33%), tubing kinks in 10 (16%), urethral cuff erosion in 8 (13%), scrotal hematoma in 6 (9%), control assembly malfunction in 4 (6%) and cuff leaks in 4 (6%). Of the 20 patients with previous pelvic radiation 2 (10%) had at least 1 erosion, compared to 5 of 97 (5%) in the nonirradiated group. At followup 5 patients did not have at least 1 component of the AMS800 device indwelling (2 cuffs and 3 entire devices had been removed).     

The "opening time" and "pelvic floor electromyographic lag time": two novel tools in the assessment of the anorectal evacuation time.

Rectal evacuation necessitates rectal contraction and pelvic floor muscles relaxation; it is not known which action precedes the other. We investigated the hypothesis that pelvic floor muscles relaxation precedes rectal contraction so that rectal contents find the anal canal already opened. Electromyographic activity of the external anal sphincter as well as anal and rectal pressures were recorded during rectal balloon distension and evacuation. Pelvic floor muscles electromyographic lag time (time from start of pelvic floor muscles relaxation to start of evacuation) and opening time (time from start of rectal contraction to start of evacuation) were measured. Rectal balloon distension in increments of 20 mL up to 100 mL effected progressive increase of both external anal sphincter electromyography and anal pressure. At 120 mL balloon distension up to 180 mL, external anal sphincter electromyography and anal pressure exhibited gradual decrease whereas rectal pressure showed no changes. At 200 to 220 mL rectal balloon distension, rectal pressure increased and anal pressure decreased, while external anal sphincter showed no electromyographic activity; rectal balloon was expelled. The opening time recorded a mean of 1.8 +/- 0.7 s and pelvic floor muscles electromyographic lag time of 2.2 +/- 0.9; the two recordings showed no significant difference (p > .05). These, two diagnostic tools in anorectal investigations are presented: the opening time and pelvic floor muscles electromyographic lag time. Pelvic floor muscles relaxation preceded rectal contraction. As there is no significant difference between opening time and pelvic floor muscles electromyographic lag time, it appears easier to apply the latter as it is simple, objective, and noninvasive.     

Addition of a Second Urethral Cuff to Enhance Performance of the Artificial Urinary Sphincter

Purpose

Stress urinary incontinence may persist in approximately 15 percent of men following implantation of a standard artificial urinary sphincter. The ability of a second urethral cuff to provide satisfactory continence without additional operative complications was investigated.

Materials and Methods

A second urethral cuff was placed to enhance performance of the artificial urinary sphincter in 5 men with stress urinary incontinence following radical prostatectomy. A stainless steel 3-way tubing connector allowed for addition of a second cuff to the standard artificial urinary sphincter without the kinking problems previously observed with a flexible 3-way connector. In 4 consecutive men a second cuff was added at operative revision of an existing artificial urinary sphincter that had failed to produce satisfactory continence. A double cuff artificial sphincter was placed initially in 1 man.

Results

Of 5 men 4 had satisfactory and 1 had improved continence with the double cuff artificial urinary sphincter. The stainless steel 3-way tubing connector eliminated kinking complications.

Conclusions

Implantation of a second urethral cuff can provide satisfactory urinary continence in men with an artificial urinary sphincter and persistent incontinence. Placement of a double cuff artificial urinary sphincter may also represent appropriate initial intervention in men with significant stress urinary incontinence.     

Total pelvic floor repair for the treatment of neuropathic fecal incontinence.

Long-term results of postanal repair are poor. Many patients with neuropathic incontinence have evidence of anterior pelvic floor weakness. A more comprehensive surgical repair has therefore been developed that involves postanal repair, anterior levatorplasty, and external sphincter plication. Primary total pelvic floor repair was performed in 22 women with neuropathic fecal incontinence. Fourteen patients who remained incontinent after conventional postanal repair underwent secondary anterior levatorplasty and external sphincter plication (two stages). Neither resting nor squeeze anal pressures were influenced by any of these procedures. However, pelvic floor descent at rest and straining was significantly decreased following primary total pelvic floor repair and secondary pelvic floor repair (p less than 0.05) but not by postanal repair. Complete continence for liquids, solids, and flatus was achieved in 41% of patients after primary total pelvic floor repair and in 14% after secondary anterior levatorplasty and external sphincter plication, but in only 4% after postanal repair. Only one patient after primary total pelvic floor repair and one after secondary anterior levatorplasty and external sphincter plication had persistent incontinence compared with 18 (38%) after postanal repair.     

Endorectal ultrasound (ERUS) in pelvic disorders

Endorectal ultrasound (ERUS) imaging is a complex process using electronic devices to control ultrasound waves and produce images of anatomic structures. It is a simple, cheep and well-tolerated procedure that provides excellent images of rectal and anal canal wall and pelvic floor muscles together with surrounding organs and tissues. The direct imaging of anal canal and pelvic floor muscles with surrounding tissues allows one to identify sphincter defects, anorectal abscesses and fistulas as well as great variety of benign and malignant pathology of the pelvis. Basically, techniques for ERUS are very similar, but there are some slight modifications regarding equipment, indications, and localization of pathologic process. We describe the technique, indications, results and pitfalls of ERUS with the Bruel and Kjaer type 1850 endosonic probe with 7 and 10 MHz transducers in benign pelvic disorders.     

External anal sphincter repair using the overlapping technique in patients with anal incontinence and concomitant pudendal nerve damage

BACKGROUND: No single surgical technique has so far emerged as the optimal approach to treat defects of the anal sphincter in patients with postpartum fecal incontinence. Our approach is to repair the external sphincter using the overlapping technique to optimize morphological and clinical outcome. The results were correlated with preoperatively determined pudendal nerve function. METHODS: Thirty-five patients were followed up for three years after repair of the external anal sphincter. The patients had grade 2 (n = 29) or grade 3 (n = 6) fecal incontinence. Nineteen (54 %) patients had a concomitant defect of the internal anal sphincter and 28 (80 %) had abnormal pelvic floor EMG findings. Before surgery, all patients underwent conservative treatment with biofeedback and electrostimulation. The muscle ends were overlapped with Vicryl 4-0 sutures. A standardized protocol was used for the perioperative management in all patients. RESULTS: Of the 35 patients who underwent overlapping repair of the external anal sphincter, 32 (91 %) had a satisfactory result at 3-year follow-up based on sonomorphological criteria. These 32 patients were continent for solid and liquid stools. Six of the 35 patients (17 %) continued to have flatus incontinence. Two (6 %) patients were improved and one patient (3 %) had unchanged incontinence. Pudendal nerve damage had no effect on the outcome of surgery. CONCLUSIONS: Our findings at 3-year follow-up show good results for the overlapping repair of the external anal sphincter in terms of morphology and clinical symptoms. This outcome depends on an adequate preoperative pelvic floor conditioning, optimal perioperative management, and use of a standardized operative technique. Surgical repair of the morphological defect is recommended even in patients with pudendal nerve damage.     

Combined urinary and faecal incontinence

Combined urinary and faecal (liquid or solid) incontinence (double incontinence) is the most severe and debilitating manifestation of pelvic floor dysfunction. The community prevalence is 9–19% (urinary) and 5–10% (faecal), increasing with age. Pathophysiological factors include childbirth-associated external anal sphincter injury and pudendal nerve damage, pelvic floor descent, menopause, collagen disorders and multiple sclerosis-like conditions. The presence of crossed reflexes between the bladder, urethra, anorectum and pelvic floor in animal studies may explain the comorbidity of urinary and faecal urgency. Surgical treatment is based on aetiology and combined optimum techniques such as colposuspension or suburethral sling with overlapping sphincteroplasty. Other methods for improving sphincteric control include sacral nerve neuromodulation, bulking agents and artificial sphincters.     

Experiences with the artificial urinary sphincter in the irradiated patient.

The AMS800 artificial urinary sphincter was placed in 16 men who underwent previous pelvic irradiation for adenocarcinoma of the prostate. A total of 13 patients had undergone external beam irradiation and 3 had had iridium seed implants. The sphincteric cuff was placed in the bulbar urethra in all patients, with a pressure regulating balloon of 51 to 60 or 61 to 70 cm. water. Overall social continence rate was 87%. Total complication rate was 25% with a rate of erosion and/or infection of 12.5%. We advocate that with meticulous technique, use of a low pressure balloon and delayed primary cuff activation, the artificial urinary sphincter can be placed with a reasonable success rate in post-irradiated men with urinary incontinence.     

New anal retractor in pelviperineology: preliminary experience

The authors illustrate the technical characteristics and the clinical results of a new anal retractor in proctology and pelviperineology This new device, designed and produced by the authors, enables the surgeon to operate in a traditional or isostatic modality. The small external diameter and the original morphology seem to guarantee a less invasive introduction into the anal canal with minimal mechanical damage to the anal sphincter. The main indications for its use are pelvic floor surgery and patients with a diagnosis of anal incontinence or with suspected sphincter damage. Forty consecutive patients referred to our Coloproctological Unit have been operated on with the new anal retractor with no complications. The operative results obtained with the new device are defined as good in 75% and optimal in 10%. The anal retractor seems easy to use in all the surgical procedures with a much better safety profile with regard to anal sphincter.     

Advances in the surgical treatment of fecal incontinence

Although surgery for fecal incontinence has been shown to be effective, it is still very challenging and sometimes frustrating. Overlapping sphincteroplasty, by far the most common procedure, is effective in patients with sphincter defects; however, recent data suggest that success rates tend to deteriorate over time. A thorough preoperative evaluation incorporates numerous factors, including patient characteristics, severity of incontinence, type and size of the sphincter defect as assessed by physical examination, anal ultrasound, and anorectal physiology studies including anal manometry, electromyography, and pudendal nerve terminal motor latency assessment. The use of these evaluation methods has allowed better patient assignment for a variety of new alternative treatment options. Innovations in the surgical treatment of fecal incontinence range from simple, office-based sphincter augmentation techniques to surgical implantation of mechanical devices. This article reviews 5 alternative surgical treatment options for fecal incontinence: injection of carbon-coated beads in the submucosa of the anal canal, radiofrequency energy delivery, stimulated graciloplasty, artificial bowel sphincter, and sacral nerve stimulation.     

Artificial anal sphincter in severe fecal incontinence: outcome of prospective experience with 37 patients in one institution

OBJECTIVE: To evaluate the outcome of artificial anal sphincter implantation for severe fecal incontinence in 37 consecutive patients operated on in a single institution from 1993 through 2001. SUMMARY BACKGROUND DATA: Implantation of an artificial anal sphincter is proposed in severe fecal incontinence when local treatment is unsuitable or has failed. The results of this technique have not been determined yet, and its place among the various operative procedures is still debated. METHODS: Artificial anal sphincters were implanted in 37 patients from 1993 through 2001. All patients had complete fecal incontinence and had failed to respond to medical treatment. Median duration of incontinence was 16 years. The causes of incontinence were sphincter disruption (19 patients), hereditary malformations (2 patients), and neurologic disease (16 patients). Six patients had had previous surgery for fecal incontinence. Assessment was made by physical examination (anal continence, rectal emptying) and anorectal manometry. RESULTS: In the first 12 patients, six devices had to be removed (50%); the cause of failure was found in all cases, and this allowed contraindications to be defined. Among the next 25 patients, 23 had an uncomplicated postoperative follow-up, and 5 developed seven complications: control pump change (n = 3), balloon migration (n = 1), and major rectal emptying difficulties in patients with obstructive internal rectal procidentia (n = 2). The artificial anal sphincter had to be removed definitively in three cases, representing the failure rate of this technique in the authors' experience (12%); two other devices had to be removed temporarily and the patients are awaiting reimplantation. In this latter group of 25 patients, 80% have an activated sphincter: continence for liquid stool is normal in 78.9%, continence for gas in 63.1%. Seven patients have rectal emptying difficulties, minor in five and major in two. Manometric studies showed mean pressures of 110 and 37 cm H(2)O with closed and open sphincter, respectively, with a mean duration of artificial sphincter opening of 128 seconds. CONCLUSIONS: The long-term functional outcome of artificial anal sphincter implantation for severe fecal incontinence is satisfactory; adequate sphincter function is recovered and the definitive removal rate is low. Good results are directly related to careful patient selection and appropriate surgical and perioperative management after a learning curve of the surgical team.     

Role of the artificial urinary sphincter in the treatment of stress incontinence in women.

The artificial urinary sphincter (AUS) is rarely indicated in the treatment of women with stress incontinence because most of these women have deficient urethral support rather than pure sphincter weakness and the AUS is a treatment specifically for pure sphincter weakness. The procedure is contraindicated after pelvic radiotherapy and after previous sling surgery because of the high incidence of cuff erosion. Otherwise the artificial sphincter gives excellent results comparable to those seen in men with post-prostatectomy incontinence and much better than in neuropathic bladder dysfunction.     

Electrophysiological recordings during the peripheral nerve evaluation (PNE) test in complete spinal cord injury patients

Up until now, the exact mechanism by which neuromodulation using sacral nerve stimulation works still remains unknown. Recent studies of pelvic floor contraction during peripheral nerve evaluation (PNE) have shown that several muscle responses are reflexly mediated. However, whether these reflexes originate from a segmental level within the sacral spinal cord or from supraspinal neuronal centers involving spino-bulbospinal pathways remains to be determined. Therefore, recordings of external anal sphincter reflexes during PNE in complete spinal cord injury (SCI) patients was performed. Three patients with complete SCI (two female and one male) suffering from neurogenic incontinence underwent the first stage of a stimulator implant (peripheral nerve evaluation). Stimulation was obtained through an electrode placed in the S3 foramen. Concomitantly, the latency of the response of the striated anal sphincter was measured using a concentric needle electrode placed in the striated part of the anal sphincter. Repeated measurements within an interval of 30 min were performed to confirm the reliability of the responses. In all subjects, reflex responses of early and late latencies could be recorded. The early response showed a mean latency of 41.2 ms (range 33.3-62 ms), which corresponds to a segmental reflex, similar to the pudendo-anal reflex. The late response appeared with a mean latency of 189.4 ms (range: 183.3-197.8 ms) and with high variability and fatigability, suggesting a reflex response organized at polysegmental spinal levels. Despite successful foramina lead placement, none of our complete SCI patients showed any improvement of neurogenic incontinence after 5 days of treatment by sacral nerve stimulation. The findings confirm that the anal contractions observed during peripheral nerve evaluation are reflex responses mediated by afferent pathways. Both the early and late reflex responses are of spinal origin, since they were obtained in complete SCI patients in whom all spino-bulbo spinal loops are supposed to be interrupted. The finding that neuromodulation is working in non-neurogenic patients but is less successful in complete SCI patients could give evidence that preserved spino-bulbo spinal loops contribute to the positive effects of neuromodulation. The role of an eventual spino-bulbo spinal loop acting during neuromodulation in non-neurogenic patients has to be assessed in further studies.     

Surgical anatomy of the somatic terminal innervation to the anal and urethral sphincters: role in anal and urethral surgery

PURPOSE: The gross anatomy of the pudendal nerve branches was studied to identify more precisely the neuroanatomical relationship in the region of the anal canal, bladder neck and proximal urethra. Such knowledge is essential for the development of surgical techniques that avoid nerve injury in sphincteroplasty for anal and urinary stress incontinence, and in pudendal canal decompression. MATERIALS AND METHODS: The pudendal nerve terminal branches were dissected in 7 female and 5 male formalin fixed cadavers, including 6 fully mature neonates and 6 adults, a mean age of 37.6 years. The nerves were traced from the pudendal nerve to their termination in the anal and urethral sphincters, and pelvic floor muscles. RESULTS: The inferior rectal nerve occupied the lower half of the ischiorectal fossa. Immediately after emerging from the pudendal canal it extended a motor branch to the levator ani muscle and the cutaneous perianal and scrotal branches. The nerve terminated in the external anal sphincter at the 3 and 9 o'clock positions. Inside the pudendal canal the perineal nerve gave rise to a scrotal branch which joined the scrotal branch of the inferior rectal nerve to form the common scrotal nerve. About 2 to 3 cm. from the pudendal canal the perineal nerve extended a branch to the bulbocavernosus muscle and divided into the terminal scrotal and motor branches, which penetrated the striated urethral sphincter at the 3 and 9 o'clock positions. The deep dorsal nerve of penis or clitoris coursed forward into the ischiorectal fossa, emerged from the deep perineal pouch and penetrated the suspensory ligament to the dorsum of the penis or clitoris. CONCLUSIONS: The identification of the precise anatomical relation of the somatic nerve termination to the anal and urethral sphincters seems vital to avoid sphincter denervation during surgery for the correction of fecal and stress urinary incontinence.     

Intestinal implantation of an artificial sphincter]

In order to restore anal sphincteric function, artificial AMS sphincter was used with his 3 components: the peri-intestinal cuff giving anal sphincter tone, the pump used for active opening and the pressure regulating balloon. In the same fashion a continent valve may be created on an intestinal segment as a part of a reconstructed bladder. In this case the pump may be replace by a subcutaneous port allowing fluid injection to adjust volume and pressure in the cuff. Two patients with fecal incontinence related to sequela of a high imperforate anus syndrome were implanted. Follow-up is greater than 1 year with normal continence in the day for the first case (degree 2) and continence day and night in the second case. Artificial valve has been implanted in seven cases of neobladder pouch (or related situations), with in 4 cases very good results and in 3 cases a failure (Follow-up 3-36 months).     

Anal Sphincter Repair in the Treatment of Anal Incontinence - When and How to Do it?

Anal incontinence is a disease of high prevalence. For many patients the disease causes severe stress and often results in social isolation. Whenever a sphincter lesion has been diagnosed by digital rectal examination and endosonographic access, anal sphincter reconstruction can be performed with the same results either in overlapping or in end-to-end suture technique. sing these procedures, in more than 60 % of patients the continence can be initially improved. However, benefit decreases after 5 years down to 40-50 %. The prognosis gets worse with increasing age and supplementary descending pelvic floor. Anal repair with reconstruction of internal and external sphincters is performed in neurogenic incontinence. This can be achieved by posterior or anterior anal repair (total pelvic floor repair). Nowadays these procedures are not common, due to unsuccessfulness. Instead, sacral nerve stimulation as a more expensive but less invasive method has displaced the anal repair on this indication. Interpretation of the published results remains delicate because of heterogenous evaluation criteria of postoperative outcome: subjective amelioration, postoperative satisfaction and quality of life, improvement of incontinence score or achievement of complete anal continence. However, it is proven that after immediate reconstruction of traumatic sphincter lesions the postoperative outcome is better than a two-step operation with primary ostomy.