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.     

Assessment of a novel implantable artificial anal sphincter

PURPOSE: The aim of the study was to test a new implantable artificial anal sphincter in the porcine model. METHOD: The artificial sphincter, which includes an inflatable expander that compresses and flattens the bowel against a pillow, was implanted in 16 animals and studied for periods of up to 20 weeks. The anal sphincters were destroyed, and the efficacy of the device in rendering the animals continent was studied. RESULTS: Of the 11 animals in which the artificial sphincter was regularly closed, 8 completed the study and were continent during 85 percent of activation times. There was no evidence of ischemic injury. Major complications were related only to failure of the control pumps of the device. CONCLUSION: This study suggests that this neosphincter produces fecal continence without intestinal ischemia. At present reliability is limited only by the performance of the pump.     

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.     

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.     

Stress urinary incontinence in women caused by severe sphincter hypotonia. Goebbel-Stoeckel intervention as alternative to artificial sphincter. Apropos of 26 cases treated between January 1985 and January 1994

Stress urinary incontinence with low urethral closure pressure and urethral mobility is often treated by artificial urinary sphincter. Our retrospective report in 19 patients evaluates the sling procedure as an alternative to the artificial urinary sphincter (7 patients). All patients had a preoperative clinical and urodynamic evaluation. 13 patients were continent (68.4%) in the sling procedure group and 5 in the sphincter group. Continence remained stable with a mean follow-up of 77 months (range: 39-110 months). 2 patients had urgency and none had dysuria. The sling procedure gave us the same results as sphincter with less morbidity.     

Surgery of primary sphincter incontinence

A thorough functional analysis of the anorectal continence organ and the pelvic floor is a prerequisite for adequate treatment of incontinence. If conservative therapy has failed, corrective surgery on the basis of careful patient selection may well lead to improvement of continence. In our experience, plastic surgery of both the anterior levator ani muscle and the sphincter ani externus muscle is the treatment of choice for idiopathic incontinence.     

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.     

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.     

Effect of delivery on the anal sphincter

SPHINCTER TEARS: Vaginal delivery can lead to tears in the anal sphincters. Total perineal distension following expulsion concerns less than 1% of all deliveries. Initially, sphincter tears generally go unnoticed although echographically detectable defects can be found in one-third of all primiparturients. The inner or outer sphincter may be involved alone or in combination as is seen in half of the cases. NEUROLOGICAL LESIONS: Moderate signs of incontinence (gas, urge) are frequently reversible although the long-term outcome remains unknown. In half of the cases, perineal denervation is secondary to stretch lesions of the pudendal nerve terminasions. FAVORING FACTORS: Primiparity, forceps delivery, fetal macrosomy, and certain presentations (breech, occipitoposterior) may favor sphincter lesions. DIAGNOSIS: A complete examination of the posterior perineum is required with anorectal manometry, a perineal electrophysiologic study, and a transanal ultrasound study whenever function signs are found at the post partum follow-up. TREATMENT: The therapeutic strategy is guided by the exploration results. In case of symptomatic rupture of the external sphincter, sphicteroplasty is needed followed by functional rehabilitation therapy with biofeedback. Women who have suffered traumatic lesions of the posterior perineum should be carefully followed for signs of secondary incontinence. Cesarean section may be indicated as a preventive measure in case of a new pregnancy.     

Etiology and epidemiology of anal incontinence

In twenty-five patients with a clinical diagnosis of suspected sacroiliitis conventional radiography, CT and MRI were performed. In ten patients no abnormalities were demonstrated. In thirteen cases CT and MRI revealed sacroiliitis. In two patients with normal plain films and CT para- and intraarticular changes of signal intensity suggested suspicious sacroiliitis. MRI can be considered as an important imaging modality for early diagnosis of sacroiliitis. In eighteen patients with a firm diagnosis of ankylosing spondylitis and plain films of the thoracolumbar junction suggesting destructive Romanus and Anderson inflammatory lesions MRI was done. Two distinct groups of inflammatory changes were found. In ten patients MRI findings compatible with active inflammatory enthesitis were revealed at the disco-vertebral junction. In eight cases focal and linear changes of signal intensity within the intervertebral disks suggested an active inflammation. Using MRI the spectrum of inflammatory changes in sero-negative spondylitis can be presented. In sixteen patients with definite clinical diagnosis (psoriatic arthritis--thirteen cases and Reiter's syndrome--three cases) plain films and MRI of small hand joints were performed. The patients fell into two distinct groups. In the first MRI findings could not be differentiated from those seen in rheumatoid arthritis. In nine cases the distribution and extent of soft tissue findings were different, similar to changes seen in enthesitis. Therefore, on the basis of MRI findings in small peripheral joints easier differential diagnosis between sero-negative spondyloarthritides and rheumatoid arthritis is possible. In five patients with a diagnosis of Reiter's syndrome having clinical signs of enthesitis plain films and MRI of calcaneus were done. MRI revealed findings compatible with active inflammation which resembled those seen at the attachment of the annulus fibrosus and collateral ligaments of the small hand joints.     

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.     

Sustained internal sphincter hypertonia in patients with chronic anal fissure

Tenascin is a large extracellular matrix glycoprotein which is widely distributed in normal, hyperplastic and neoplastic tissues. Its function is unknown but it has been associated with the epithelial-stromal interactions, such as cell adhesion and movement which take place, e.g. in morphogenesis, cellular proliferation and neoplasia. In this study, we investigated tenascin expression in 70 benign, dysplastic and malignant melanocytic tumors by using immunohistochemistry and monoclonal anti-tenascin 143DB7C8 antibody on paraffin sections. In all types of benign nevi, both intradermal, compound and junctional, there was a moderate expression of tenascin at the dermoepidermal junction and in the papillary dermis. In dysplastic nevi, the fibrotic areas in the papillary dermis also showed a moderate staining for tenascin. Invasive malignant melanomas showed the strongest expression of tenascin. In addition to the staining at the dermo-epidermal junction and in the papillary dermis, there was a variable expression of tenascin in the reticular dermis. Intracytoplasmic tenascin was detected both in primary melanomas and melanoma metastases. In conclusion, we have shown that tenascin expression is moderately increased in benign and dysplastic melanocytic tumors and greatly increased in malignant melanomas and melanoma metastases. The function of tenascin may be related to the cellular-stromal interactions and it is possibly associated with the proliferation and spread of the melanocytic tumors.     

The AMS 800 sphincter in urinary incontinence after prostatic surgery. Apropos of 16 patients

OBJECTIVE: To present the results of a series of artificial sphincters implanted for urinary incontinence after prostatic surgery. PATIENTS AND METHODS: From 1987 to 1996, artificial sphincters were implanted for urinary incontinence after prostatic surgery, consisting of one transvesical prostatectomy, 11 prostatic resections and 4 radical prostatectomies. All these patients were evaluate by urine culture, cystourethrography and urethrocystoscopy. Eleven patients underwent urodynamic assessment. The AMS 800 artificial sphincter was used. RESULTS: The mean interval between onset of incontinence and implantation was 18 months. The mean follow-up after implantation of the sphincter was 6 years. An operative wound of the bulbar urethra did not prevent implantation of the sphincter, but required repair and prolonged catheterization (12 days). The mean duration of catheterization was 6 days. The overall functional result was 81% (13 case), and 75% of sphincters were functional at 5 years. Five revisions were necessary to maintain functioning of the sphincter in 2 cases of rupture and 1 displacement of the balloon, 1 case of urethral atrophy and 1 rupture of the pump. Three explanations, 2 total and 1 partial, were performed. Two reimplantations were performed after 12 months and 26 months respectively. CONCLUSION: The AMS 800 artificial sphincter currently represents an effective treatment for urinary incontinence due to sphincter insufficiency after prostatic surgery. However, an old artificial sphincter may require revision to restore function.     

Control of shunt infection. Report of 150 consecutive cases

The author analyzes 150 consecutive ventriculovenous, ventriculoperitoneal, and lumboperitoneal shunt procedures with particular attention to shunt colonization by Staphylococcus epidermidis. There was one primary infection with Staphylococcus epidermidis early in the series, and in two other cases, the organism was felt to be a secondary invader. In those procedures involving either primary placement or revision of a ventriculovenous shunt, there was not a single infection. The operative protocol that has virtually eliminated Staphylococcus epidermidis is outlined.