Long-term results of total pelvic floor repair for postobstetric fecal incontinence

PURPOSE: This study was designed to assess the long-term results of total pelvic floor repair for postobstetric neuropathic fecal incontinence. METHOD: Sixty-three of 75 women who had undergone total pelvic floor repair for postobstetric neuropathic fecal incontinence were traced and interviewed a median of 36 (18–78) months after surgery. Thirty-nine patients agreed to repeat anorectal physiology. RESULTS: Six patients required further surgery for persistent incontinence (colostomy, 4; graciloplasty, 2). For the remaining 57 patients, incontinence improved greatly in 28 (49 percent) patients, mildly in 13 (23 percent), and not at all in 16 (28 percent); daily incontinence was present in 41 patients (73 percent) before the operation but persisted in 13 (23 percent). Only eight (14 percent) patients were rendered completely continent; those with marked improvement were socially more active than those with little or no improvement. Resting and maximum squeeze pressures, anal canal sensation, rectal sensation, and pudendal nerve terminal motor latency did not predict outcome. Perineal descent, obesity, and a history of straining before the operation were all associated with a poor outcome. CONCLUSION: Total pelvic floor repair rarely renders patients with postobstetric neuropathic fecal incontinence completely continent but substantially improves continence and lifestyle in approximately one-half of them. The operation is less successful in obese patients and in those with a history of straining or perineal descent.Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

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.     

Randomized trial of internal anal sphincter plication with pelvic floor repair for neuropathic fecal incontinence

PURPOSE: This study was designed to examine the role of adjuvant internal anal sphincter plication in women with neuropathic fecal incontinence undergoing pelvic floor repair. METHODS: We completed a randomized trial with symptomatic and physiologic assessment before and after surgery. RESULTS: There was no symptomatic advantage of adding internal sphincter plication; the mean improvement of functional score was 3.61±1.82 (standard deviation;P <0.01) following pelvic floor repair alone compared with 2.80±1.66 (standard deviation;P <0.01) when adjuvant internal anal sphincter plication was added. The addition of internal sphincter plication was associated with a significant fall in maximum anal resting and squeezing pressures (P <0.01). CONCLUSIONS: Addition of internal sphincter plication is not advised in women with neuropathic fecal incontinence treated by pelvic floor repair.     

Risk factors in childbirth causing damage to the pelvic floor innervation

The innervation of the pelvic floor musculature is damaged in both stress urinary incontinence and idiopathic (neurogenic) anorectal incontinence. Because childbirth has been considered to be a causative factor in stress incontinence we have assessed the effect of childbirth on the innervation of the pelvic floor musculature in 122 consecutively referred women. They were investigated 48–72 h and 2 months after delivery; 51 were also studied 6 months prior to delivery. In 45 of these 51 women delivered vaginally, EMG studies of the external anal sphincter muscle showed that the fibre density (FD) increased from 1.38±0.14 before delivery to 1.57±0.19 2 months after delivery (p<0.01). There was no change in the FD in the external anal sphincter muscle after delivery in 20 women delivered by Caesarean section. The pudendal nerve terminal motor latency (PNTML) measured 48–72 h after delivery was increased in the 102 women delivered vaginally compared to 34 nulliparous control subjects. Analysis of the whole group of 122 women showed that multiparity, forceps delivery, increased duration of the second stage of labour, third degree perineal tear and high birth weight were important factors leading to pudendal nerve damage. Epidural anaesthesia had no effect on pudendal nerve function. Modification of these obstetric risk factors may ultimately reduce the frequency of stress urinary and faecal incontinence in women.     

Is there a role for concomitant pelvic floor repair in patients with sphincter defects in the treatment of fecal incontinence?

BACKGROUND AND AIMS: More than half of all patients who undergo overlapping anal sphincter repair for fecal incontinence develop recurrent symptoms. Many have associated pelvic floor disorders that are not surgically addressed during sphincter repair. We evaluate the outcomes of combined overlapping anal sphincteroplasty and pelvic floor repair (PFR) vs. anterior sphincteroplasty alone in patients with concomitant sphincter and pelvic floor defects. PATIENTS AND METHODS: We reviewed all patients with concomitant defects who underwent surgery between February 1998 and August 2001. Patients were assessed preoperatively by anorectal manometry, pudendal nerve terminal motor latency, and endoanal ultrasound. The degree of continence was assessed both preoperatively and postoperatively using the Cleveland Clinic Florida fecal incontinence score. Postoperative success was defined as a score of 相似文献   

Electrical Stimulation and Pelvic Floor Muscle Training With Biofeedback in Patients With Fecal Incontinence: A Cohort Study of 281 Patients

Purpose Pelvic floor rehabilitation is an appealing treatment for patients with fecal incontinence but reported results vary. This study was designed to assess the outcome of pelvic floor rehabilitation in a large series of consecutive patients with fecal incontinence caused by different etiologies. Methods A total of 281 patients (252 females) were included. Data about medical history, anal manometry, rectal capacity measurement, and endoanal sonography were collected. Subgroups of patients were defined by anal sphincter complex integrity, and nature and possible underlying causes of fecal incontinence. Subsequently patients were referred for pelvic floor rehabilitation, comprising nine sessions of electric stimulation and pelvic floor muscle training with biofeedback. Pelvic floor rehabilitation outcome was documented with Vaizey score, anal manometry, and rectal capacity measurement findings. Results Vaizey score improved from baseline in 143 of 239 patients (60 percent), remained unchanged in 56 patients (23 percent), and deteriorated in 40 patients (17 percent). Mean Vaizey score reduced with 3.2 points (P < 0.001). A Vaizey score reduction of ≥ 50 percent was observed in 32 patients (13 percent). Mean squeeze pressure (+5.1 mmHg; P = 0.04) and maximal tolerated volume (+11 ml; P = 0.01) improved from baseline. Resting pressure (P = 0.22), sensory threshold (P = 0.52), and urge sensation (P = 0.06) remained unchanged. Subgroup analyses did not show substantial differences in effects of pelvic floor rehabilitation between subgroups. Conclusions Pelvic floor rehabilitation leads overall to a modest improvement in severity of fecal incontinence, squeeze pressure, and maximal tolerated volume. Only in a few patients, a substantial improvement of the baseline Vaizey score was observed. Further studies are needed to identify patients who most likely will benefit from pelvic floor rehabilitation. Supported by grant 945-01-013 of the Netherlands Organization for Health Research and Development. Presented at the United European Gastroenterology Week, Copenhagen, Denmark, October 15 to October 19, 2005. Reprints are not available.     

Total fecal incontinence-a new method of gluteus maximus transposition: Preliminary results and report of previous experience with similar procedures

Since 1986, different procedures of gluteus maximus transposition have been performed, by one of the authors, in 10 patients with total anal incontinence not amenable to sphincter repair, due to congenital anomalies (four), sphincteric denervation (three) or after severe trauma (three). Variable degrees of long-lasting fecal control were obtained in all but one patient, with great improvement in six. Difficulties for achieving a closed anus without muscular tension of the neosphincter, together with the morbidity associated with anal wound infection, determined the reasons for the successive use of different techniques (Biström, Hentz, Schoamaker) until the authors, in 1990, designed a new procedure (Devesa). Although the reported experience with this technique described here is limited to only four patients, our impression is that the method is easier, has less morbidity, and achieves better short-term functional results, derived from a thick, tension-free neosphincter.Read at the 7th Annual Scientific Meeting of the Sidney Colorectal Surgical Society, Internacional Programmes in Colorectal Surgery, Hamilton Island, Australia, September 2, 1990.     

Rectal prolapse and anal incontinence treated with a modified Roscoe Graham operation

The results of abdominal mobilization of the rectum and repair of the pelvic floor behind the anorectal junction are reported in 23 patients with rectal prolapse, being accompanied by some form of anal incontinence in 12. Within 20 months, on the average, three patients had recurrent prolapse. Two thirds of the patients with incontinence for solid and/or fluid feces were cured for prolapse as well as incontinence. Seven became constipated, while 14 were fully satisfied. Seven of eight patients with a highly reduced tone of the external sphincter before surgery had a marked improvement after surgery. The results do not differ greatly from those after the suspension operation or repair of the pelvic floor in front of the rectum, despite being more physiologic, but suggest that simultaneous suspension and abdominal repair of the pelvic floor may avoid the need for a secondary postanal repair from below in patients with persistent incontinence after suspension surgery. A controlled, randomized trial is advocated.     

Dynamic magnetic resonance imaging evaluation of the structural and functional results of postanal repair for neuropathic fecal incontinence

PURPOSE: The aim of this study was to determine whether dynamic magnetic resonance imaging of the pelvic floor can discriminate between patients who improve after postanal repair for neurogenic fecal incontinence and those who remain symptomatic. METHODS: Pelvic floor measurements obtained during dynamic magnetic resonance imaging in eight females whose anal incontinence had improved after postanal repair were compared with those from nine females who remained symptomatic. All subjects also underwent standard anorectal physiology testing. RESULTS: There was no significant difference between groups with respect to any measurement of anterior or middle pelvic floor compartments. Additionally, there was no difference in posterior pelvic floor configuration when symptomatic patients were compared with those who had improved. However, dynamic magnetic resonance measurements revealed patients who remained symptomatic had significantly greater posterior pelvic floor weakness. Anorectal physiology was unable to differentiate between groups. CONCLUSIONS: There is no difference in static pelvic floor measurements when subjects remaining symptomatic after postanal repair are compared with those who have improved. In contrast, dynamic measurements may be able to predict failure in those who demonstrate excessive posterior pelvic floor mobility.     

Randomized,Controlled Trial of Biofeedback With Anal Manometry,Transanal Ultrasound,or Pelvic Floor Retraining With Digital Guidance Alone in the Treatment of Mild to Moderate Fecal Incontinence

BACKGROUND: A prospective, three-armed, randomized, controlled trial was performed to assess whether pelvic floor exercises with biofeedback using anal manometry or transanal ultrasound are superior to pelvic floor exercises with feedback from digital examination alone in terms of continence, quality of life, physiologic sphincter strength, and compliance. Its secondary objectives were to assess whether there are any differences in these outcomes between biofeedback with transanal ultrasound vs. anal manometry and to correlate the physiologic measures with clinical outcome. METHODS: One hundred twenty patients with mild to moderate fecal incontinence were randomized into one of three treatment groups: biofeedback with anal manometry, biofeedback with transanal ultrasound, or pelvic floor exercises with feedback from digital examination alone. Commencing one week after an initial 45-minute assessment session, patients attended monthly treatments for a total of five sessions. Each session lasted 30 minutes and involved sphincter exercises with biofeedback that involved instrumentation or digital examination alone, and patients were encouraged to perform identical exercises twice per day between outpatient visits. RESULTS: One hundred two patients (85 percent) completed the four-month treatment program. Across all treatment allocations, patients experienced modest but highly significant improvements in all nine outcome measures during treatment, with 70 percent of all patients perceiving improvement in symptom severity and 69 percent of patients reporting improved quality of life. With the possible exception of isotonic fatigue time, there were no significant differences between the three treatment groups in compliance, physiologic sphincter strength, and clinical or quality-of-life measures. Correlations between physiologic measures and clinical outcomes were much stronger with ultrasound-based measures than with manometry. CONCLUSIONS: Although patients in this study who completed pelvic floor exercises with feedback from digital examination achieved no additional benefit from biofeedback and measurement with transanal ultrasound or manometry, it may be that the guidance received through digital examination alone offered patients in the pelvic floor exercise group an effective biofeedback mechanism. Contrary to our hypothesis, the use of transanal ultrasound offered no benefit over manometry, but the use of ultrasound for isotonic fatigue time and isometric fatigue contractions provided potentially important physiologic measures that require further study. This study has confirmed, through a large sample of patients, that pelvic floor retraining programs are an effective treatment for improving physiologic, clinical, and quality-of-life parameters in the short term.     

Bilateral gluteus maximus transposition for anal incontinence

Seven patients (five men and two women) ranging in age from 26 to 65 years (¯x=44) underwent bilateral gluteus maximus transposition for complete anal incontinence. The indications for operation were sphincter destruction secondary to multiple fistulotomies (n=4), bilateral pudendal nerve damage (n=2), and high imperforate anus (n=1). The procedure is performed without the use of a diverting colostomy. The inferior portion of the origin of each gluteus maximus is detached from the sacrum and coccyx, bifurcated, and tunneled subcutaneously to encircle the anus. The ends are then sutured together to form two opposing slings of voluntary muscle. Postoperatively, six patients regained continence to solid stool, two to liquid stool as well, and only one patient in this group was able to control flatus. Although resting pressures remained unchanged, voluntary squeeze pressures were restored by this operation. In addition, rectal sensation was markedly improved, which helps make this a worthwhile procedure for properly selected patients.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Kombinierte Stuhl- und Harninkontinenz

Background: Double (urinary and fecal) incontinence is relatively common in the elderly. 6% of men and 9.5% of women over 50 years suffer from combined urinary and fecal incontinence. 50% of males and 60% of females with fecal incontinence have concurrent urinary incontinence. The high rate of concurrence of urinary and fecal incontinence is due to an almost identical innervation of the urinary bladder and the rectum and the close vicinity and partial identity of the muscular sphincter mechanisms. Classification: There are two causal entities of double incontinence: 1. neurogenic disorders, 2. pelvic floor dysfunction. Neurogenic disorders can be classified in central and peripheral nervous lesions. Pelvic floor dysfunction can be due to nerve injury or direct muscular lesions. According to the International Continence Society, urinary incontinence is classified into five categories: 1. stress incontinence, 2. urge incontinence, 3. reflex incontinence, 4. overflow incontinence, 5. extraurethral incontinence. With respect to anal incontinence, the first four groups are important. Diagnosis: The diagnostic evaluation comprises meticulous history, physical examination including neuro-urological status, rectal and in females standardized pelvic examination, urinalysis, sonography of the kidneys and bladder after voiding (postvoid residual urine). In women, a transrectal ultrasound of the bladder, urethra and the pelvic floor is important and can replace lateral cystourethrography. In complex cases, dynamic NMR imaging is helpful. Functional investigations include urodynamic studies with uroflowmetry, filling and voiding cystometry and urethral pressure profiles and rectomanometry. Conclusion: For optimal therapy of double incontinence, an interdisciplinary approach is necessary.     

Outcome of sphincteroplasty combined with surgery for urinary incontinence and pelvic organ prolapse

PURPOSE: This is the first reported prospective study comparing outcome and cost in patients undergoing sphincteroplasty for anal incontinence vs. sphincteroplasty performed in combination with one or more procedures for urinary incontinence and/or pelvic organ prolapse. METHODS: We analyzed 44 patients with fecal incontinence who underwent anal sphincter repair alone (20 patients) or in combination with procedures for urinary incontinence or pelvic organ prolapse (24 patients). Information regarding risk factors for fecal incontinence, the degree of incontinence, and the extent that incontinence limited social, physical, and sexual activity was prospectively obtained from questionnaires. Clinic chart reviews and follow-up telephone interviews provided additional data. A cohort of case-matched patients who underwent only urogynecologic procedures was compared retrospectively for operative time, hospital cost, length of stay, and postoperative complications. RESULTS: There were no major complications in any group. The functional outcomes, physical, social, and sexual activity were similar in all three groups. Twenty-two of 24 patients who underwent the combined procedures were glad that they had both procedures concomitantly. CONCLUSION: Combination pelvic floor surgery provides good outcomes and is cost effective. This approach should be offered to women with concurrent problems of fecal and urinary incontinence and/or pelvic organ prolapse.     

Pelvic floor procedures produce no consistent changes in anatomy or physiology

PURPOSE: Postanal repair was designed to restore both anatomy and function of the anal canal in neurogenic fecal incontinence. In most series, the degree of continence is improved in fewer than 50 percent of patients. Adding anterior levatorplasty and sphincter plication (total pelvic floor repair) is claimed to improve functional results. We performed a randomized trial comparing postanal and total pelvic floor repair for neurogenic incontinence. METHOD: Twenty female patients were studied. All had Type D incontinence (Parks and Browning). Anal manometry, defecography, and grading of the degree of continence were repeated 12 weeks after surgery to assess changes in clinical, manometric, and radiologic parameters. Statistical analysis was done using Wilcoxon's signed-rank test and Wilcoxon's two-sample test. RESULTS: Continence improved in eight patients. Differences among clinical, manometric, and radiologic data were not statistically significant. CONCLUSION: Pelvic floor repair procedures produce no consistent changes in anatomy or physiology. Clinical improvement is caused by creation of a local stenosis or by the placebo effect rather than by improvement of muscle function.Presented at the annual meeting of the Dutch Society of Surgery, Veldhoven, The Netherlands, May 18 to 19, 1995.     

Endosonography in the evaluation of anal function after primary repair of a third‐degree obstetric tear

Background: Disruption of the anal sphincter occurs in 0.6%–6% of women during delivery and almost half have persistent defecatory symptoms despite primary repair. Our aim was to prospectively analyse anal endosonography and rectoanal manometry after primary repair of a third‐degree obstetric tear in order to compare the findings with the clinical outcome. Methods: Twenty‐one women aged 27–41 (mean 31.5 years) who had undergone primary suture of a third‐degree disruption of the anal sphincter were interviewed on their pelvic floor function and explored by manometry and endosonography 4 months after delivery. Results: Twelve women had anal incontinence. External sphincter defect was identified on endosonography in 22% continent and in 91% incontinent women (P?P?2 O) than in incontinent women (48?±?36?cm H ₂ O; P?=?0.04), but no anal pressure threshold could achieve better results than endosonography in predicting the clinical outcome. Conclusion: After primary repair of a third‐degree obstetric tear, endosonographic pattern of the anal sphincter correlates with the continence status.     

Traumatic anal incontinence

PURPOSE: This study was designed to describe the surgical technique and discuss the possible beneficial role of unilateral gluteus maximus transposition supplementing and supporting a tensile-direct anal Sphincteroplasty. METHODS: Based on our experience with bilateral gluteus transposition, direct apposition of the remaining muscular ends combined with unilateral gluteus transposition (to avoid the tendency of the sphincter ends to separate) was undertaken in two patients with severe destruction of more than half of the anal muscular ring. RESULTS: Both postoperative courses were uneventful. Three months after colostomy closure, both patients were classified as Pescatori's B1. CONCLUSION: As with any other combined surgical technique, the benefit derived may be attributed entirely to one of the procedures, but it is our impression that the gluteus transposition was worthwhile in achieving satisfactory repair.Presented at the Fourth Biennial Congress of the European Council for Coloproctology, Marseille, France, May 27 to 29, 1992.     

Anal vector volume analysis: an effective tool in the management of pelvic floor disorders

Introduction  

Different trials have investigated the role of conventional anal manometry in the diagnosis of pelvic floor disorders. The aim of the present study is to define the role and the effectiveness of vector anal manometry and vector asymmetry index scoring in the assessment of pelvic floor disorders i.e. fecal incontinence and obstructed defecation.     

Functional changes after physiotherapy in fecal incontinence

Background Physiotherapy is a common treatment option in patients with fecal incontinence. Although physiotherapy may result in relief of symptoms, to what extent improvement is associated with changes in anorectal function is still unclear.Aim The aim of the present study was to investigate prospectively how anorectal function changes with physiotherapy and whether these changes are related to changes in fecal incontinence score.Methods Consenting consecutive patients (n=266) with fecal incontinence (91% women; mean age, 59 years) underwent anorectal manometry, anal and rectal mucosal sensitivity measurements, and rectal capacity measurement at baseline and after nine sessions of standardized pelvic floor physiotherapy. These findings were compared with changes in Vaizey incontinence score.Results On follow-up 3 months after physiotherapy, squeeze pressure (p=0.028), as well as urge sensation threshold (p=0.046) and maximum tolerable volume (p=0.018), had increased significantly. The extent of improvement was not related to age, duration of fecal incontinence, menopause, and endosonography findings. All other anorectal functions did not change. An improvement in the Vaizey score was moderately correlated with an increase in incremental squeeze pressure (r=0.14, p=0.04) and a decrease in anal mucosal sensitivity threshold (r=0.20, p=0.01).Conclusions Physiotherapy improves squeeze pressure, urge sensation, and maximum tolerable volume. However, improved anorectal function does not always result in a decrease in fecal incontinence complaints.     

Prospective trial of pelvic floor retraining in patients with fecal incontinence

PURPOSE: Our aim was to prospectively evaluate pelvic floor retraining (PFR) in improving symptomatic fecal incontinence. METHODS: PFR was used to treat 30 patients with fecal incontinence (28 women; age range, 29–85 (median, 68) years). PFR was performed by a physiotherapist in the outpatient department according to a strict protocol and included biofeedback using an anal plug electromyometer. Manometry (24 patients), pudendal nerve terminal motor latency (PNTML, 16 patients), and anal ultrasound (14 patients) were done before commencing therapy. Independent assessment of symptoms was done at the commencement of therapy, at 6 weeks, and at 6 and 12 months posttherapy. RESULTS: Twenty patients (67 percent) had improved incontinence scores, with eight patients (27 percent) being completely or nearly free of symptoms. Of 28 patients followed up longer than six months, 14 achieved a 25 percent or greater improvement at six weeks, which was sustained in all cases. Fourteen had an initial improvement of less than 25 percent, with only four (29 percent) showing later improvement (P <0.0001). There was no relationship between results of the therapy and patient age, initial severity of symptoms, etiology of incontinence, and results of anal manometry, PNTML, and anal ultrasound. CONCLUSIONS: PFR is a physical therapy that should be considered as the initial treatment in patients with fecal incontinence. An improvement can be expected in up to 67 percent of patients. Initial good results can predict overall outcome.Read at the Tripartite Colorectal Meeting, London, United Kingdom, July 8 to 10, 1996.     

Prospective,randomized, controlled trial of proximally based vs. distally based gluteus maximus flap for anal incontinence in cadavers

PURPOSE: The aim of this study was to compare the lengths of proximally based and distally based gluteus maximus flaps created as for anal sphincter reconstruction in soft human cadavers. METHODS: Twelve soft cadavers were used in this prospective, randomized, controlled study. In each cadaver, a proximally based flap of the gluteus maximus muscle was performed on one side and a distally based flap on the other. All flaps were carefully dissected with neurovascular preservation by one surgeon. After the dissected flap was placed across the anus, the length of the flap that projected beyond the anus was measured. The differences between such lengths of both types of flaps were assessed by paired t-test. RESULTS: The average lengths of the parts that projected beyond the anus for proximally based and distally based flaps were 8.08 and 4.50 (standard deviation, 0.51 and 0.79) cm, respectively. The average difference was 3.58 (standard deviation, 0.51) cm, which was statistically significant (P < 0.001). CONCLUSION: Results showed that proximally based flaps were significantly longer than distally based flaps and that transposition and wrapping around the anus with proximally based flaps were always easily performed without tension. These findings support the use of unilateral proximally based gluteus maximus flaps instead of unilateral or bilateral distally based flaps in patients with anal incontinence. The location of the neurovascular pedicle of the gluteus maximus was consistent at 1 cm superior and lateral to ischial tuberosity. Knowledge of this landmark allows quick and safe dissection of the gluteus maximus flap.