Technic of overlapping sphincter anal repair in the treatment of traumatic anal incontinence

Faecal incontinence is an important disabling symptom in the affected patients. Classically, we divide faecal incontinence in two main types: neurogenic faecal incontinence and traumatic anal incontinence. Traumatic anal incontinence is due to causes damaging sphincteric mechanism directly. The aim of the present study was to evaluate the outcome of overlapping sphincter anal repair procedure in the management of traumatic anal incontinence. To this end we studied 27 patients with traumatic anal incontinence who underwent an overlapping sphincter anal repair procedure according to the method described by Parks and McPartlin in 1971. Mean follow up was up three years and was based mainly both on clinical evaluation with anorectal exploration and manometric values carried out on a 6 monthly basis. When the outcome was evaluated in terms of faecal continence our date were similar to those reported by Parks and Fang. In the subjects studied we haven't reported any major complications apart from one case of abscess, one case of wound's infection and one case of stenosis which were efficaciously treated. Our findings supported the view that overlapping sphincter anal repair procedure is the surgical approach of choice in the patients with traumatic anal incontinence.     

Anal and urinary incontinence after obstetric anal sphincter rupture]

The aim of the study was to assess the long term impact of obstetric anal sphincter rupture on the frequency of anal and urinary incontinence, and identify factors to predict patients at risk. In 94 consecutive women who had sustained an obstetric anal sphincter rupture, anal manometry, anal sphincter electromyography and pudendal nerve terminal motor latency at three months post partum was performed. A questionnaire regarding incontinence was sent between two to four years post partum. Forty-two percent of responders had anal incontinence, 32% had urinary and anal incontinence. Overall, 56% of the women had incontinence symptoms. The occurrence of anal incontinence was associated with pudendal nerve terminal motor latencies > 2.0 milliseconds and the occurrence of urinary incontinence was associated with the degree of rupture, the use of vacuum extraction and previous presence of urinary incontinence. Thirty-eight percent of the women with incontinence wanted treatment, but only a few had sought medical advice.     

Stimulated gracilis neosphincter: a new procedure for anal incontinence

Creutzfeldt-Jakob disease (CJD) is a transmissible neurodegenerative disorder characterized by the accumulation of proteinase-resistant prion protein (PrP) in the brain. Pathological changes in the cerebellum are common and include atrophy of the granular layer, spongiform change in the molecular layer, and astrocytic gliosis of the cerebellar cortex and white matter. In most cases of sporadic CJD immunohistochemistry for PrP shows widespread granular deposits of the scrapie isoform of the prion protein (PrPSc) in the cerebellar cortex. In a minority of cases plaque-like deposits of PrPSc are detectable. The genetic background of this phenomenon was investigated in 47 cases of sporadic CJD. Immunohistochemistry using antibodies against PrP was performed in brain autopsy specimens. A genetic analysis of the prion protein gene (PRNP) showed overrepresentation of homozygosity for either methionine (M/M) or valine (V/V) at the polymorphic codon 129 in CJD patients as compared to 74 controls. No significant difference in allele frequency between the 2 groups was found. Plaques or plaque-like PrPSc deposits were found in 9 cases of CJD and were associated with the presence of valine at codon 129 on at least 1 allele of PRNP. CJD patients homozygous for valine (V/V) were on an average more than 5 years younger than patients with M/M or M/V at codon 129.     

Results of artificial sphincter in severe anal incontinence. Report of 14 consecutive implantations

PURPOSE AND METHODS: Fourteen AMS 800 (American Medical Systems, Minneapolis, MN) urinary artificial sphincters have been consecutively implanted in 13 patients with total incontinence for stool of various causes (traumatic or postoperative, 7; congenital, 3; neurologic, 2; idiopathic, 1). No proximal stoma was constructed but was already present in one patient before implantation. RESULTS: Sepsis occurred in two patients. Removal of sphincter and colostomy was necessary in three patients: one of these two had developed sepsis, one had perineal ulceration before activation of the sphincter in a severely scarred perineum, and one had severe pain in a radiation-injured anorectum. Sphincter-related failure occurred once by rupture of the cuff in a constipated woman after two years of satisfactory function. Reimplantation of a new cuff restored normal continence in this patient. After median follow-up of 20 (range, 4-60) months, nine of ten patients with a functioning sphincter were continent for stool, and five were also continent for gas. Failure occurred in one patient because the cuff was too large to occlude the anal canal. This patient is awaiting reimplantation. Four patients experienced easily controlled difficulties with evacuation of feces. Anal pressure with inflated cuff varied from 43 to 94 (mean, 58 +/- 12) cm H2O. CONCLUSION: These results show that an artificial sphincter has a role in the treatment of severe anal incontinence when local therapies are not applicable or have failed.     

Surgical repair of fecal incontinence. Correlation of sonographic anal sphincter integrity with subjective cure

We examined the relationship between left ventricular hypertrophy (LVH) and renal and retinal damage in 174 untreated patients with essential hypertension. As an index of renal and retinal damage, we examined proteinuria and retinal vascular change. LVH was diagnosed according to left ventricular mass obtained from echocardiography. Of the hypertensive patients, 111 patients (64%) had LVH. The incidences of proteinuria and advanced retinal vascular change were higher in patients with LVH than in those without LVH. In a multiple regression model, there was a significant positive correlation between left ventricular mass and proteinuria, as well as diastolic blood pressure, sex, age and body mass index. In conclusion, proteinuria is related to elevated left ventricular mass in patients with essential hypertension.     

Clinical effects of childbirth with median episiotomy and anal sphincter injury on fecal incontinence of primiparous women

Obstetric damage of the anorectal continence organ can lead to impaired anal continence. To assess the effect of birth, either with or without direct injury of the anal sphincter, 123 primiparae were studied. 41 patients with a midline episiotomy and 82 patients with an additional injury of the anal sphincter were assessed at a median of 21 weeks postpartum and compared with 18 healthy volunteers. Anorectal manometry as well as a standardized questionnaire were employed. Patients with an additional injury of the anal sphincter reported persistent flatus incontinence significantly more often (p = 0.0069) than patients with a midline episiotomy only. Incontinence of solid or liquid stool occurred only transiently. Compared to nulliparae in all primiparae a significant shortening of anal canal and a decreased squeeze pressure were observed. In addition, a significantly reduced resting pressure was seen in patients with an anal sphincter injury. The rectoanal inhibitory reflex was absent significantly more often following anal sphincter tear (p = 0.0023). Vaginal delivery, both with and without anal sphincter injury, leads to early detectable changes in anorectal sphincter function.     

Combining the strength-duration curve of the external anal sphincter with manometry for the assessment of faecal incontinence

BACKGROUND: The strength-duration curve of a muscle is thought to be a measure of its innervation. This study was designed to evaluate the ability of the strength-duration curve of the external anal sphincter to discriminate between controls and patients with faecal incontinence. METHODS: Forty-three women with faecal incontinence due to sphincter weakness were studied together with 45 age-matched women with no disorders of defaecation. Strength-duration curves of the external anal sphincter and anorectal manometry were recorded for all subjects with the additional measurement of pudendal nerve terminal motor latency in the incontinent group. RESULTS: Logistic regression was performed using resting and voluntary squeeze pressures and current strengths at 28 different pulse durations to develop a predictive equation for incontinence. Only currents at 1 and 6 ms were significant predictors. When anorectal manometry data were included, only the current required to elicit contraction at 1 ms was necessary. The following regression equation can be applied to predict continence in this population with a sensitivity of 95 per cent and a specificity of 100 per cent: logit(P)=4.1605-(0.0559 x squeeze pressure)-(0.1755 x resting pressure)+0.8622I(1 ms). A negative value indicates continence. CONCLUSION: The strength-duration curve, when used in conjunction with anorectal manometry, may have a role in the investigation of faecal incontinence.     

Effects of anal invasive treatment and incontinence on mental health and psychosocial functioning of adolescents with Hirschsprung's disease and low anorectal anomalies

BACKGROUND/PURPOSE: Recent studies of adolescents with Hirschsprung's disease (HD) and low anorectal anomalies (LARA) showed persistent impairment of fecal control in both groups, but very different mental and psychosocial outcome. METHODS: To explore possible reasons for these differences, 19 adolescents with HD (aged 10 to 20 years; median, 16) operated on by the Duhamel technique were compared with 17 adolescents with LARA (aged 12 to 20 years; median, 15). The 36 adolescents were assessed for treatment procedures, bowel function, and mental and psychosocial outcome by data collected from medical records, physical examination, semistructured interview, and standardized questionnaires. The parents of 30 adolescents were also interviewed and completed questionnaires. RESULTS: Duration of anal invasive treatment procedure and current bowel function were associated with mental and psychosocial outcome. The treatment variable, duration of anal dilation, was the most significant predictor of the adolescents's mental health (R2 = .41, P < .01), whereas chronic family difficulties and parental warmth together with the current bowel function variables, fecal and flatus continence function, best explained the variance in psychosocial outcome (R2 = .77, P < .0001). Thus, the differences in treatment procedures and continence function between the HD and LARA groups may partially explain differences in mental and psychosocial outcome. CONCLUSIONS: These findings suggest that anal dilatation and continence dysfunction may have negative impact on mental health and psychosocial functioning. Indications for and ways of performing the procedure of dilation, and the treatment of persistent incontinence problems, are questioned.     

Stroke and incontinence

BACKGROUND: Urinary incontinence in the acute stage of stroke is seen as a predictor of death, severe disability, and an important factor on hospital discharge destination. Therefore, it is an important measure of stroke severity that not only affects the lives of stroke survivors but also those of caregivers. SUMMARY OF REVIEW: A number of studies have linked the presence of bladder dysfunction in stroke survivors to various neurological lesions in areas thought to be primarily involved in micturition. However, neurological deficits may affect management of bladder control secondarily by apraxia or aphasia, for example, and a significant number of strokes occur in individuals already experiencing incontinence. CONCLUSIONS: Despite incontinence being such an important prognostic feature, there are many gaps in our knowledge of the relationship of stroke and incontinence, particularly fecal incontinence. There are almost no studies on the influence of achieving continence on outcome or how this might be brought about. This article reviews the literature on this important topic and highlights deficiencies in our knowledge and areas of future research.     

MR imaging of the anal sphincter in multiparous women using an endoanal coil: correlation with in vitro anatomy and appearances in fecal incontinence

OBJECTIVE: The aim of this study was to correlate the components of the normal female anal sphincter seen on high-resolution MR images with the in vitro anatomy and to describe the change in appearances of these components in multiparous women with fecal incontinence. SUBJECTS AND METHODS: Ten asymptomatic female volunteers (32-72 years old; mean, 54 years old) and 22 women with fecal incontinence were studied. In six patients (26-68 years old; mean, 49 years old) fecal incontinence began immediately after childbirth; in the remaining 16 patients (45-77 years old; mean, 58 years old) fecal incontinence developed 15- 30 years after childbirth. In the latter group of patients, terminal motor latencies of the pudendal nerve were measured. Imaging was done on a 0.5-T Picker Asset unit and on a 1.0-T Picker HPQ unit. A saddle geometry endoanal receiver coil was used for all imaging. T1-weighted spin-echo (720-820/20 [range of TR/TE]), T2-weighted spin-echo (2500/80 [TR/TE]), fast spin-echo (4500/96 [TR/ effective TE]), and short inversion time inversion recovery (2500/80 [TR/TE]; inversion time, 107 msec) MR images were obtained in transverse, coronal oblique, and sagittal planes. Images were assessed for integrity of the sphincter components. A nonpaired separate-variance t test was used to compare thickness of individual muscle components between patients with delayed-onset fecal incontinence and asymptomatic age-matched volunteers. Degree of muscle atrophy was correlated with degree of delay in the terminal motor latency of the pudendal nerve. RESULTS: The high resolution obtained with an endoanal coil allowed differentiation of the various muscle components of the anal sphincter complex. The internal sphincter was seen as a ring of homogeneously high signal intensity with a low-signal-intensity rim that was rich in collagen and contained neurovascular bundles. The external anal sphincter, which had low signal intensity on T1- and T2-weighted images, was shown as three components: subcutaneous, superficial, and deep. In six patients who had fecal incontinence that began immediately after childbirth, endoanal MR imaging revealed the site and extent of a tear. All tears were confirmed at surgery. In the 16 patients who had fecal incontinence that began several years after childbirth, atrophy of the external sphincter was revealed in all cases in the superficial and deep components. The internal sphincter remained normal. However, we found that the degree of atrophy of individual components of the external sphincter did not correlate with the degree of delay in pudendal nerve conduction. CONCLUSION: MR imaging with an endoanal coil reveals the integrity and bulk of individual muscle components of the anal sphincter in multiparous women with fecal incontinence.     

Etiology of sarcoidosis

Since sarcoidosis was first recognized as a distinct clinical entity, investigators have speculated that a transmissible agent may cause sarcoidosis. Recent attempts at directly isolating infectious organisms or indirectly detecting microbial DNA or RNA from sarcoid tissue have led to inconclusive results. Studies on the immunopathogenic origins of sarcoidosis have provided evidence of persistent antigenic stimulation at sites of inflammation that are associated with dysregulated cytokine production. To date, however, the challenge of defining the cause of sarcoidosis remains unmet.