Sphincter injury after anal dilatation demonstrated by anal endosonography.

Anal dilatation is still used in the treatment of anal fissure and haemorrhoids. Using anorectal physiology and anal endosonography we have studied 12 men presenting with faecal incontinence following anal dilatation. Resting anal pressures were low, pudendal nerve latencies were normal; 11 men had a disrupted internal anal sphincter and in ten this was extensively fragmented. Three also had defects of the external anal sphincter. These findings demonstrate for the first time the nature of the structural injury which may be caused by anal dilatation.     

Calculations of flow resistance in the juxtacanalicular meshwork

The structure of the juxtacanalicular meshwork (JCM) was analyzed morphometrically, and the resulting data were used to calculate the resistance to flow through this tissue. Two models of the JCM were presented and compared. In the first (Model A), aqueous humor was assumed to flow via open channels within a solid framework, while, in the second (Model B), these open spaces were assumed to be filled with extracellular matrix gel. An expression giving the resistance of such a gel as a function of gel concentration was presented and tested on corneal and scleral stroma. Morphometry of normal and glaucomatous human eyes showed that Model A underpredicted the resistance of the JCM by factors of 10-100, suggesting that a GAG or proteoglycan gel may control the flow resistance of this tissue. This was supported by Model B, which showed that measured bulk concentrations of GAGs were consistent with gel concentrations needed to account for the estimated resistance of the JCM in vivo. Some limitations and implications of Model B were discussed.     

Background-protein effects on fluorophotometric data.

Fluorescent tracers are commonly used in fluorophotometric studies of ocular fluids and tissues that contain background protein. Background-protein concentrations were found to decrease or increase significantly the measure of fluorescence emitted from solutions containing sodium fluorescein, fluorescein-labeled dextran, or fluorescein-labeled horseradish peroxidase. The effect of background protein on fluorescence was expressed as a function of the specific fluorescent tracer, tracer concentration, and background-protein concentration; it can be corrected in the analysis of fluorophotometric data. Fluorophotometric studies--particularly those in which the background-protein level is expected to be abnormally high, such as postoperative and pathologic studies--may need to include either a data correction based on measured effects of background protein on tracer fluorescence or, in the case of clinical investigations, recognize at least the potential for a range of possible interpretations.     

Perineal examination as a predictor of underlying external anal sphincter damage

Objective To assess the relation between perineal inspection and sphincter integrity in parous women.
Design Prospective observational study.
Setting District general hospital.
Population Fifty-seven consecutive parous women attending a gynaecology clinic for problems unrelated to the pelvic floor.
Methods A detailed history of bowel function and mode of delivery obtained; the perineum inspected to determine the presence and position of scarring, and anal endosonography performed.
Results In 19 women with an intact perineum on inspection, endosonography showed perineal scarring in five, with both perineal and sphincter scarring in three. Four had urge faecal incontinence. Three patients had a perineal tear only on inspection, but this group was too small for analysis and was discounted. Nine had an episiotomy scar only. Endosonography demonstrated perineal scarring in four, and combined perineal and sphincter scarring in two; one woman in this group had urge faecal incontinence. Twenty-six women had episiotomy and perineal tears on inspection. Endosonography revealed underlying perineal scarring in five women, with combined perineal and sphincter scarring in 14; six women in this group had urge faecal incontinence and one passive incontinence for flatus. Sonographically the scarring was anterior and circumferential rather than radial, and mostly left-sided, whereas on inspection episiotomy and perineal scarring were right sided.
Conclusions A normal perineum on clinical examination does not exclude underlying sphincter damage. The incidence of sphincter damage increases significantly when an episiotomy scar is associated with a perineal tear.     

A randomized controlled trial of electromagnetic therapy in the primary care management of venous leg ulceration

OBJECTIVE: The aim was to establish the potential efficacy, tolerabilityand side-effect profile of electromagnetic therapy as an adjunctto conventional dressings in the treatment of venous leg ulcers. METHOD: A prospective, randomized, double blind controlled clinicaltrial was carried out in a dedicated leg ulcer clinic basedin one urban general practice. Nineteen patients with leg ulcersof confirmed venous aetiology were assessed. The main outcomemeasures were rate and scale of venous leg ulcer healing, changesin patient-reported pain levels, quality of life, degree ofmobility, side effect profile and acceptability to patientsand staff. RESULTS: Sixty-eight per cent of patients attending this dedicated clinicachieved improvements in the size of their ulcer (4, 21%, healedfully) and in reduced pain levels (P < 0.05) during the trial,despite the chronicity of ulcer histories. Patients treatedwith electromagnetic therapy at 800 Hz were found at day 50to have significantly greater healing (P < 0.05) and paincontrol (P < 0.05) than placebo therapy or treatment with600 Hz. All patients reported improved mobility at the end ofthe study. The electromagnetic therapy was well tolerated bypatients, with no differences between groups in reporting adverseevents, and proved acceptable to staff. CONCLUSION: Despite the small numbers in this pilot study, electromagnetictherapy provided significant gains in the healing of venousleg ulcers and reduction in pain. Keywords. Electromagnetic therapy, RCT, leg ulcers, primary care.