Correlation of anorectal electromanometry and anorectal three-dimensional ultrasound findings in patients with fecal incontinence / Correlação dos achados da eletromanometria anorretal e ultrassonografia anorretal tridimensional nos pacientes portadores de incontinência fecal

Objective: To show the correlation of anorectal electromanometry and three-dimensional anorectal ultrasonography in patients with fecal incontinence. Method: Prospective study involving 34 women (mean age: 55 years) with a diagnosis of fecal incontinence. The samples were submitted to three-dimensional anorectal ultrasonogra- phy/Echodefecography and anorectal electromanometry. Results: Based on anorectal electromanometry data, 70.5% of 34 patients had hypotonia at rest, 64.7% had hypotonic contraction, 52.9% had both hypotonia at rest and hypotonic contraction, and 44.1% had anismus. By three-dimensional anorectal ultrasonography, 32.3% had internal anal sphincter injury, 79.4% had external anal sphincter injures, and 26.4% had both internal and external anal sphincter injuries. In 38.2%, anismus was suggested and 50% showed rectocele. Overall, only 5.8% had normal results for anorectal electromanometry combined with three-dimensional anorectal ultrasonography. Kappa index was 0.297 and the presence of anismus through anorectal electromanometry and three-dimensional anorectal ultrasonography was compared by Student's t test application, with p<0.0001. Conclusion: We conclude that there was a reasonable agreement in the comparison of sphincter hypotonia by anorectal manometry and sphincter injury by anorectal three-dimensional ultrasonography in a group of patients with fecal incontinence. The incidence of anismus in patients with fecal incontinence is considerable, and the therapeutic approach in these patients should be modified. (AU)

RESUMO Objetivo: Demonstrar a correlação entre eletromanometria anorretal (EMAR) e ultrassonografia tridimensional anorretal (3D-US) em pacientes com incontinência fecal. Método: Estudo prospectivo envolvendo 34 mulheres (média de idade: 55 anos) com diagnóstico de incontinência fecal. As amostras foram submetidas à 3D-US/Ecodefecografia e EMAR. Resultados: Com base nos dados de EMAR, 70,5% das 34 pacientes exibiam hipotonia em repouso, 64,7% exibiam contração hipotônica, 52,9% hipotonia em repouso e contração hipotônica, e 44,1% exibiam anismus. Com base nos achados de 3D-US, 32,3% exibiam lesão no esfíncter anal interno, 79,4% exibiam lesão no esfíncter anal externo, e 26,4% em ambos os esfíncteres anais interno e externo. Pela 3D-US, em 38,2% das pacientes houve indício de anismus, e em 50%, retocele. No total, apenas 5,8% obtiveram resultados normais combina- dos para EMAR e 3D-US. Foi constatado um índice Kappa = 0,297 e, no teste t de Student, a comparação de anismus por EMAR e por 3D-US obteve significância de p<0,0001. Conclusão: Concluímos ter havido concordância razoável ao ser comparada a manomatria anorretal para hipotonia esfinctérica e a ultrassonografia tridimensional anorretal para lesão esfinctérica em um grupo de pacientes com incontinência fecal. A incidência de anismus em pacientes com incontinência fecal é considerável, e a abordagem terapêutica para esses pacientes deve ser modificada. (AU)

Incontinencia fecal del adulto / Fecal incontinence in adults

The aim of this paper is to review the knowledge of this pathology by highlighting the clinical evolution, study and treatment. These different aspects need a multidisciplinar approach, because of their complex physiopathology, possible association with urinary incontinence and prolapse of the three compartments of the pelvis. The fecal incontinence (FI) constitutes a highly prevalent pathology that affects at least 2 percent of the population and up to 45 percent of the patients in nursing homes. This pathology can cause serious problems in physical, psychological, social, and economical levels. The clinical evaluation may identify or suspect the cause, and guide the study of FI. The initial treatment of the FI should always be medical one, often associated to biofeedback and the surgical treatment should be only reserved for refractory FI. Sphincteroplasty is indicated by defined defaults of the external sphincter, with good initial results (at least 70 percent) that fall to 50 percent in 5 years. The artificial neosphincter and the dynamic graciloplasty represent an option for patient without sufficient sphincter mass for a plasty. In the last few years new techniques have appear with promising results, as the neuromodulation that uses electrodes in the sacral plexus or applied to the posterior tibial nerve. In conclusion the IF is a problem of large prevalence but kept in shadows because the patients tend to have reticence to declare it, and the doctors to inquire about. The focus should be multidisciplinary and the initial treatment must be medical one. The surgical treatment should be reserved for refractory FI.

El propósito de esta revisión es actualizar los conocimientos sobre esta patología, destacando su evolución clínica, estudio y tratamiento, aspectos que ameritan un enfoque multidisciplinario, ya que, además de su compleja fisiopatología, puede asociarse a incontinencia urinaria y prolapso de los tres compartimentos de la pelvis. La incontinencia fecal (IF) constituye una patología altamente prevalente que afecta al menos un 2 por ciento de la población y hasta el 45 por ciento de los pacientes en casas de reposo; cuyas consecuencias pueden ocasionar al paciente serios problemas físicos, psicológicos, sociales y económicos. La evaluación clínica puede identificar o sospechar la causa de la IF, y guiar el estudio de la misma. El tratamiento inicial de la IF debe ser siempre médico, a menudo asociado a biofeedback, y el tratamiento quirúrgico reservarse para la IF refractaria a estas medidas. La esfinteroplastía está indicada en defectos definidos del esfínter externo, con buenos resultados iniciales (al menos 70 por ciento) que caen hasta el 50 por ciento al cabo de 5 años. El neoesfínter artificial y la graciloplastía dinámica representan opciones para pacientes sin masa esfinteriana suficiente para una plastía. En los últimos años han aparecido técnicas más promisorias como la neuromodulación que utiliza electrodos en el plexo sacro o aplicados al tibial posterior. En conclusión la IF es un problema de gran prevalencia, pero soterrado, ya que los pacientes son reticentes a declararla y los médicos a indagarla. Su enfoque debe ser multidisciplinario y su tratamiento inicial, médico, reservando la cirugía para casos refractarios.

Evaluation of Anal Continence Function by Advanced Anal Manometric Parameters

PURPOSE: Anal manometry is one of the most commonly used tests to evaluate fecal continence function. Advanced pressure parameters of the tests, such as fatigue rate index (FRI), resting rectoanal pressure gradient (RPG), cough index (CI), and radial asymmetry (RA) are recently devised to make up the inaccuracy of conventional parameters, but without solid verification. The object of this study is to investigate such parameters including conventional ones in incontinent patients compared with those in controls and to determine the significance of each parameter. METHODS: Forty-four patients with anal incontinence and 42 controls were studied. We examined conventional pressure parameters (mean resting pressure [MRP], maximum squeeze pressure [MXSP]) and advanced parameters (RPG, FRI, CI, RA), and compare those parameters with normal controls. Multiple logistic regression analysis and receiver operating characteristic curve analyses were also performed. RESULTS: No difference was detected in demographic factors between the two groups. Basic manometric parameters were significantly different between the two groups (MRP, 31.1+/-20.7 mmHg vs. 41.4+/-18.6 mmHg, P=0.0170; MXSP, 203.1+/-84.3 mmHg vs. 258.5+/-105.9 mmHg, P=0.0086). Among advanced parameters, RPG and FRI were significantly different (2.83+/-1.54 vs. 4.08+/-1.53, P=0.0003; 9+/-21.6 sec vs. 75.6+/-12.1 sec, P=0.0333), but CI and RA were not so different (0.74+/-0.45 vs. 0.61+/-0.33, P=0.1326; 22.7+/-7.0% vs. 21.1+/-7.6%, P=0.3244). Only RPG was significant in multiple logistic regression analysis (P=0.019). Areas under ROC curves were 0.65 for MRP, 0.65 for MXSP, 0.82 for RPG, and 0.73 for FRI. CONCLUSION: Among anal manometric pressure parameters, RPG and FRI as advanced parameters are more accurate than any other parameters in detecting fecal incontinence.

Diagnostic Value of Pudendal Nerve Conduction Study and Relationship with Anal Manometry in Fecal Incontinence

OBJECTIVE: To evaluate the diagnostic value of pudendal nerve terminal motor latency (PNTML) and the relationship with manometric profiles in patients with fecal incontinence. METHOD: A total of 29 patients with fecal incontinence who visited colorectal clinic were recruited. The PNTMLs of 29 patients were compared with those of normal controls (2.03+/-0.39) using one-sample t test. Patients were classified into three groups according to pudendal nerve latency; Group I (normal latency, n=8), group II (unilaterally delayed latency, n=9), group III (bilaterally delayed latency, n=12) and compared with manometric parameters (mean maximal resting pressure, mean maximal squeezing pressure, 1st sense volume, urge sense volume, maximal tolerance volume). RESULTS: The PNTML is 3.83+/-2.19 in right side, 4.57+/-2.19 in left side which are significantly delayed in patients with fecal incontinence compare to that of normal controls, 2.03+/-0.39. (p=0.031 in Rt., p=0.000 in Lt.) Among group I~III, there were no statistically significant differences in the values of mean maximal resting pressure, mean maximal squeezing pressure, 1st sense volume, urge sense volume and maximal tolerance volume. There was no correlation between the PNTML and any of manometric parameters. CONCLUSION: The PNTML is valuable in diagnosing patients with fecal incontinence. It is suggested that combined assessments are necessary to identify the cause of fecal incontinence.

Neuromodulación sacra para el tratamiento de la incontinencia anal. Experiencia piloto prospectiva en Argentina / Sacral neuromodulation in fecal incontinence. A pilot prospective experience in Argentina

INTRODUCTION: Anal incontinence is a severe physical and emotional condition that affects quality of life. Its treatment with neuromodulation, that consists in sacral roots electrical stimulation, has became a therapeutic option. OBJECTIVE: This study was designed to present the surgical technique and the first prospective experience in neuromodulation for fecal incontinence in Argentina. PATIENTS AND METHODS: Four females with severe fecal incontinence (mean score 17/20) were included. Anorectal physiology testing and anal ultrasound were performed before surgery. Due to failed medical treatment and the presence of an intact anal sphincter, sacral neuromodulation was indicated. After temporary sacral nerve evaluation, definitive neuromodulator was implanted. RESULTS: After 13 months the incontinence score and the number of weekly escapes decrese from 17/20 to 1.7/20 (p = 0.059) and from 62 to 0.2 (p = 0.059). Quality of life scores also improves but not statiscally significative. CONCLUSIONS: Sacral neuromodulation in fecal incontinence is useful. It is effective in patients who had failed maximum conservative therapies with the advantage of testing before definitive.

Introducción: La incontinencia anal constituye un severo trastorno físico y emocional que altera y limita la calidad de vida de quienes la padecen. Su tratamiento mediante neuromodulación, que consiste en la estimulación eléctrica de las raíces sacras, se ha convertido en una opción terapéutica válida. Objetivo: Presentar la técnica y la primera experiencia piloto prospectiva realizada en Argentina con neuromodulación sacra para el tratamiento de la incontinencia anal. Pacientes y métodos: Se trataron 4 pacientes de sexo femenino con incontinencia anal severa (score promedio de 17/20). Fueron estudiadas mediante manometría anorrectal, ecografía esfintérica y evaluación neurofisiológica del piso pelviano. Debido a la refractariedad a los tratamientos convencionales y a la indemnidad anatómica muscular se indicó neuromodulación sacra mediante la colocación de un electrodo estimulador cuatripolar. Se llevó a cabo la prueba de estimulación nerviosa transitoria y habiendo obtenido resultados satisfactorios, se colocó el implante definitivo. Resultados: Luego de 13 meses de seguimiento promedio el score de incontinencia disminuyó de 17/20 a 1.7/20 (p= 0.059) y el número de escapes semanales de 6.2 a 0.2 (p=0.059). También se observó una mejoría en la calidad de vida que no se vio reflejada estadísticamente. Conclusiones: La neuromodulación sacra es un procedimiento útil para el tratamiento de la incontinencia anal. Ha demostrado ser efectiva en aquellos pacientes refractarios a tratamientos convencionales con la ventaja de poder evaluar su respuesta antes del implante definitivo. Presenta baja morbilidad y corta internación.

Factors Influencing Fecal Incontinence in Complete Rectal Prolapse: A Prospective Analysis

PURPOSE: This study was undertaken to identify factors influencing fecal incontinence in rectal prolapse. METHODS: The clinical and anorectal physiologic data (anal manometry, rectal sensitivity test, pudendal nerve terminal motor latency (PNTML)) of 42 complete rectal prolapse patients were collected in a prospective database and were analyzed according to Wexner's incontinence score (0-20). RESULTS: The mean Wexner's incontinence score was 10.6. Females (n=24) were more prone to be incontinent than males (n=18)(incontinence score 14.8 vs 5.1, p<0.001). A linear regression analysis showed that increased age (r= 0.497, p=0.001), decreased maximum resting pressure (MRP) (r= 0.686, p<0.001), decreased maximum squeezing pressure (MSP)(r= 0.789, p<0.001), decreased maximal rectal tolerable volume (MTV) (r= 0.386, p=0.012) influenced the incontinence score. An absent rectoanal inhibitory reflex (RAIR) was not related to incontinence, but was related to significantly low resting anal pressure. Delayed PNTML did not influence incontinence or the MSP. In a multiple regression analysis, decreased MRP (beta= 0.383; p=0.002), decreased MSP (beta= 0.345; p =0.007) and female gender (beta=0.343; p=0.006) influenced incontinence significantly. CONCLUSIONS: Major factors influencing fecal incontinence in complete rectal prolapse were decreased MRP and MSP. Female patients were more prone to fecal incontinence than males. RAIR and MTV were not significant factors. PNTML did not show any relation to incontinence score or the anal pressure.

Differences of Anal Manometry Among Dirrhea-dominant,Constipation-dominant Irritable Bowel Syndrome and Functional Constipation / 中国医师杂志

Objective To study the differences of anal manometry among dirrhea-dominant(DD), constipation-dominant(CD) irritable bowel syndrome(IBS) and functional constipation(FC), and to evaluate effects of sex and age on these parameters.Methods Age-matched 18 DD-IBS, 14 CD-IBS and 30 FC patients were selected, and 18 volunteers as healthy controls. Anal manometry was evaluated with localized point pull-extraction technique.Results The pressure parameters in DD-IBS, CD-IBS and FC were no significantly difference from those in healthy controls, but the threshold volume of gas to induce RAIR was significantly larger(P

Evaluation of the Neurogenic Bowel by Colon Transit Time and Anorectal Manometry in the Spinal Cord Injured Patients

OBJECTIVE: To evaluate changes of colon transit time according to prokinetic medication and characteristics of the anorectal manometry in patients with neurogenic bowel due to spinal cord injury. METHOD: Twelve patients with cervical and thoracic cord injury were enrolled, and classified into complete and incomplete spinal cord injury according to the severity of injury. The colon transit time before and after prokinetic medications were measured. The anorectal manometry was performed after the first study of colon transit time. RESULTS: The colon transit time of pre-prokinetic medications were 17.1+/-12.6 hours for the right colon, 26.9+/-13.2 for the left colon, 21.5+/-14.0 for the rectosigmoid colon, and the total transit time was 65.5+/-5.3 hours. The time of post-prokinetic medications was 14.3+/-7.6 hours for the right colon, 25.8+/-10.3 for the left colon, 7.4+/-5.3 for the rectosigmoid colon, and the total transit time was 33.1+/-11.5 hours. The rectosigmoid colon transit time and total colon transit time were significantly different between pre- and post-prokinetic medications (p<0.05). In the anorectal manometry, mean resting anal pressure was 33.3+/-10.7 mmHg and maximal resting anal pressure was 99.0+/-43.4 mmHg. There were no difference in the colon transit time and anorectal manometry between complete and incomplete injured patients. CONCLUSION: The difficulties of defecation in spinal cord injured patients were not only due to uncontrolled anal sphincter but also due to dysfunction of colon motility. The prokinetic medications were effective in reducting the rectosigmoid and total colon transit time.

A Study of Anal Manometric Finding after Low Anterior Resection of Rectal Cancer

PURPOSE: Low anterior resection, irrespective of anastomotic technique, may be associated with frequent bowel movement and other bowel management difficulties. The aim of this study was to access the anorectal function after low anterior resection of the rectal cancer. METHODS: We studied 28 patients who had mid and low rectal cancer (average 8.3 cm above the anal verge) had undergone low anterior resection using stapling suture devices (average level of anastomosis was 3.8 cm above anal verge) and anal manometry was undertaken 95 times preoperatively (N=28) and 3 month (N=26), 6 months (N=22) and 12 months (N=19) postoperatively from 1992 to 1995 in Korea University Guro Hospital. RESULTS: Maximum resting pressure was reduced after resection (from 64.7 mmHg to 42.7 mmHg, change ?22 mmHg) but gradually increased and returned to preoperative level at 12 months postoperatively. Minimum perceived volume was decreased after operation (from 40.3 ml to 25 ml change of ?15.3 ml) and this change persist at 12 months postoperatively. Rectoanal inhibitory reflex was present in all patient before surgery but disappeared in most of the patient after operation. Reflex returned to normal in 4 of 22 patients at 6 months later and in 7 of 19 patients at 12 months after operation. Maximum squeezing pressure and maximum tolerable volume were not decreased after operation. CONCLUSIONS: Anorectal function (maximum resting pressure, minimum perceived volume and rectoanal inhibitory reflex) was reduced immediately after low anterior resection of rectal cancer. But this functional changes returning to normal at 6 months and most of the patients had good function at 12 months after operation.

Clinical and Physiologic Study of Encopresis

The pathophysiology of pediatric encopresis has been incomprehensible. The current study was designed to assess its clinical and physiologic findings. Moreover, outcome of treatment was evaluated. METHODS: The clinical and functional findings of 18 patients (13 boys, 5 girls) were analyzed, retrospectively. Physiologic studies for cooperative child included anal manometry (n=12), cinedefecography (n=3), and PNTML (pudendal nerve terminal motor latency, n=1). For exclusion of the organic cause, barium contrast study was carried out in all case. Patients were categorized by leading symptom as constipation or incontinence. Physiologic findings and outcome of treatment were analyzed based on the categorized groups. Biofeedback therapy by using newly-developed anal sphincter control system (KONTINENCE CLINICAL(TM)) in my institute, was underwent a mean 4.1 (range, 2~12) sessions. The outcome was analyzed in the period of 5.4 (range, 1~33) months follow-up. RESULTS: Patients were categorized as having constipation (group I, n=12) or incontinence (group II, n=6) group. In the manometric parameters, there were no statistical differences between the values of the mean resting pressure (RP), the maximum RP, and the maximum voluntary contraction between group I and II. In the cinedefecography, 3 of group I patients revealed as having the pelvic floor dyssynergia. The findings of PNTML were not specific in group II (n=1). Regarding to the therapeutic outcome, 8 of 10 patients were cured or improved. CONCLUSIONS: There were no differences in the resting and squeeze profiles of manometric parameters between two groups. However, pelvic floor dyssynergia was identified in the cinedefecography of constipated group. Conventional and biofeedback treatment for encopretic children provides acceptable outcome.

Functional Investigation with Use of Anorectal Physiology in the Patients with Fecal Incontinence

BACKGROUND: A large amount of attention in anorectal physiologic studies has been devoted to the diagnosis of fecal incontinence. The current study was designed firstly to assess the physiologic characteristics of fecal incontinence and secondly to analyze how the physiologic findings correlate with each other. METHODS: The physiologic findings of 47 patients (24 men and 23 women) were analyzed, retrospectively. Studies included anal manometry (n=38), anal electromyography/pudendal nerve terminal motor latency (PNTML) (n=30), and endoanal ultrasound (n=37). The degrees of continence were estimated by using continence grading scores (CGS) that ranged from 0 to 20 points based on the type and the frequency of incontinence. Control data were obtained from volunteers (n=23). RESULTS: The patients were categorized as having neurogenic (group I, n=25) or myogenic (group II, n=17) incontinence. Despite intensive investigations, unknown etiology was noted in 5 patients (10.4%). The CGS was not different between groups I and II. Pudendal neuropathy was found in 96% of group I and 37.5% of group II patients. Group I showed a higher value of PNTML than that of group II (2.96 1.0 msec vs. 2.07 0.48 msec, p=0.003). The CGS was proportional to the value of the PNTML in group I (r=0.476, p=0.01). However, no correlation was found between the mean PNTML and the CGS in group II. In the manometric parameters, there were no statistical differences between the values of the mean resting pressure (RP), the maximum RP, and the maximum voluntary contraction (MVC) between groups I and II. The MVC was inversely proportional to the CGS in group I (r= 0.616, p=0.02) and in group II (r= 0.664, p=0.02). No correlation was found between the PNTML and the manometric parameters. When we consider the presence of a defect or a scar as an abnormal anal ultrasound finding, such findings were more frequent in group II than in group I (group I, 20% vs. group II, 88%, p<0.001, Fisher's exact test). CONCLUSIONS: The value of the PNTML had relevance to the degree of symptoms in the patients with neurogenic incontinence. Specifically, the squeeze profiles of the manometric parameters were inversely related to the grade of incontinence. No correlation between the PNTML and the manometric parameters could be independently specified based on the etiology. Complementary examination by using the PNTML and anal ultrasound provided the only useful information to discriminate the etiology of incontinence.