Comparison of Ultrasound-Guided Transgluteal and Finger-Guided Transvaginal Pudendal Nerve Block Techniques: Which One is More Effective? / 대한배뇨장애요실금학회지

PURPOSE: Pudendal neuralgia (PN) is a painful and disabling condition, which reduces the quality of life as well. Pudendal nerve infiltrations are essential for the diagnosis and the management of PN. The purpose of this study was to compare the effectiveness of finger-guided transvaginal pudendal nerve infiltration (TV-PNI) technique and the ultrasound-guided transgluteal pudendal nerve infiltration (TG-PNI) technique.METHODS: Forty patients who underwent PNI for the diagnosis of PN were evaluated. Thirty-five of these 40 patients, who were diagnosed as PN, underwent a total of 70 further unilateral PNI. All the patients underwent PNI for twice after the first diagnostic PNI, 1 week apart.RESULTS: In the ultrasound (US)-guided TG-PNI group, the success rate was 68.8% (11 of 16) in both “pain in the sitting position” and “pain in the region from the anus to the clitoris.” The success rate of blocks in the US-guided TG-PNI group was 75% (12 of 16) in terms of pain during/after intercourse. In the finger-guided TV-PNI group, the success rate was 84.2% in both “pain in the sitting position” and “pain in the region from the anus to the clitoris.” The success rate of blocks in the fingerguided TV-PNI group was 89.5% (17 of 19) in terms of pain during/after intercourse. There was no statistically significant difference in the success rate of the 3 assessed conditions between the 2 groups (P>0.05).CONCLUSIONS: The TV-PNI may be an alternative to US-guidance technique as a safe, simple, effective approach in pudendal nerve blocks.

Radiofrecuencia pulsada para tratamiento de neuralgia de nervio pudendo bajo guía ultrasonográfica: a propósito de dos casos / Radiofrequency pulsed for treatment of neuralgia of nervio pudendo under ultrasonographic guide: a purpose of two cases

INTRODUCCIÓN: La neuralgia de nervio pudendo (NNP) se presenta como un dolor neuropático intenso, ardiente y difuso en la zona perineal, acompañado en ocasiones de hipoestesia, alodinia, hiperalgesia, sensibilidad dérmica, parestesia y entumecimiento que empeora el dolor en sedestación. Es un síndrome subdiagnosticado que, en ocasiones, se presenta refractario al tratamiento farmacológico y fisiátrico. OBJETIVOS: Evaluar la eficacia de la radiofrecuencia pulsada (RFP) guiada por ultrasonido para el tratamiento de dolor crónico, realizada a dos pacientes con NNP refractarios a tratamiento conservador. MATERIALES Y MÉTODO: Siendo positivo el bloqueo diagnóstico realizado con 0,5-1 ml de lidocaína al 2 por ciento, se practicó RFP bajo guía ecográfica a 2 pacientes (1 femenina de 36 años y 1 masculino de 54 años) con diagnóstico de NNP (según criterio de Nantes) y se realizó seguimiento a 1 semana y a 1 mes del procedimiento, observando la evolución del dolor mediante la utilización de la escala visual análoga (EVA), calidad de vida según lo informado en consulta y evolución en la ingesta y dosis de medicamentos. RESULTADOS: Luego del procedimiento la reducción del dolor fue significativa en ambos casos, en la paciente 1 (femenina) la EVA pasó de 10/10 (preoperatorio) a 1/10 a una semana del procedimiento y desapareció por completo al mes, retirándose en su totalidad la medicación indicada para la NNP. Asimismo, la paciente manifestó mejora en la calidad de vida, al no tener ya dolor durante el coito. Por su parte, en el paciente 2 (masculino), el dolor se redujo en un 50 por ciento registrándose un EVA que pasó de 8/10 (preoperatorio) a 4/10 a la semana y al mes de realizado el procedimiento. En su caso, al no haber desaparecido por completo el dolor, continuó tomando la medicación indicada (duloxetina 30 mg) y refirió poder sentarse con comodidad, ya sin el dolor intenso que lo aquejaba en esta posición, pudiendo incluso realizar un viaje de larga distancia. DISCUSIÓN: La RFP es un procedimiento efectivo en aquellos pacientes correctamente diagnosticados de neuralgia del nervio pudendo según el criterio de Nantes, refractarios a tratamiento farmacológico y/o fisioterápico, practicada por profesionales con entrenamiento y/o experiencia en la técnica de radiofrecuencia pulsada así como en el manejo de ultrasonido para ubicar sonoanatómicamente el nervio pudendo, en un ámbito seguro para la realización del procedimiento.

INTRODUCTION: The pudendal neuralgia is presented as a neurophatic pain that is intense, burning, difusse in the perineal area, sometimes accompanied by hypoesthesia, allodynia, hyperalgesia, dermal sensitivity, paresthesia and numbness that worsens by sitting. It ́s a syndrome underdiagnosed that can sometimes be refractory to traditional management like pharmacological or physical therapy. OBJECTIVES: Test the effectiveness of pulsed radiofrecuency by ultrasound-guided treatment of cronic pain done to two patients with pudendal neuralgia that were refractory to the conservative treatment. MATERIALS AND METHODS: As the diagnostic block done with 0,5-1 ml with 2 percent of lidocaine gave a positive outcome, we perform a pulsed radiofrecuency by an ultrasound-guide to two patients (36 year old female and a 54 year old male) with pudendal neuralgia diagnosted according to Nantes criteria and a tracing of 1 week and 1 month of the procedure was performed observing the pain evolution through visual analogue scale, quality of life according to the as reported in consultation and evolution in the intake and dose of medications. RESULTS: The reduction of pain was significant in both cases, in patient 1 (female) the VAS went from 10/10 (preoperative) to 1/10 to a week of the procedure and disappeared completely to 1 month, with the medicines completely withdrawn indicated for pudendal neuralgia. The female patient (1) showed improvement in the quality of life by not having pain during intercourse. On the other hand, in patient 2 (male), the pain was reduced by 50 percent, registering an EVA that went from 8/10 (preoperative) to 4/10 to 1 week and 1 month after the procedure was performed. In his case, since the pain had not completely disappeared, he continued to take the indicated medication (duloxetine 30 mg) and referred to be able to sit comfortably, without the intense pain that afflicted him in this position, even being able to travel long distances. DISCUSSION: Pulsed radiofrequency is an effective procedure in those patients correctly diagnosed with pudendal neuralgia according to the Nantes criterion, refractory to pharmacological and / or physiotherapeutic treatment, practiced by professionals with training and / or experience in the pulsed radiofrequency technique as well as in the management of ultrasound to locate the pudendal nerve sonoanatomically, in a safe environment for carrying out the procedure.

Neuropatía del pudendo como causa de dolor pélvico / Pudendal neuropathy as a cause of pelvic pain

El síndrome de atrapamiento del nervio pudendo es una de múltiples causas de dolor pélvico crónico. Hemos realizado una revisión de la literatura sobre su presentación clínica, diagnóstico y tratamiento, con el propósito de conocer los detalles más relevantes de una enfermedad que cada vez está siendo más diagnosticada, con el fin de realizar un abordaje precoz desde un punto de vista integral.

Pudendal neuralgia due to pudendal nerve entrapment is one of the many causes of chronic pelvic pain. A literature was carried out as regards its clinical presentation, and diagnostic and therapeutic approach, in order to understand the most relevant details of this disorder that is increasingly being diagnosed, with the purpose of implementing an early approach from an integral perspective.

Neurografía por resonancia magnética para la identificación de la neuralgia del nervio pudendo / Magnetic resonance neurography for the identification of pudendal neuralgia

La neuralgia del nervio pudendo (NP) es una entidad poco estudiada por imágenes. Se reconocen varias causas, tales como compresión a través de su paso por estructuras ligamentarias; estiramiento por partos laboriosos; lesiones secundarias a cirugías rectales, perineales, urológicas y ginecológicas, traumatismos con o sin fractura de huesos pelvianos; procesos inflamatorios/autoinmunes; tumores del NP, y, compresión/desplazamiento por tumores o seudotumores de pelvis. El diagnóstico de neuralgia del NP se sospecha por la clínica y se confirma por diferentes métodos, tales como las pruebas electrofisiolológicas: potenciales evocados, test de latencia motora terminal y electromiograma, y, a través de bloqueos neurales y resonancia magnética. La neurografía por resonancia magnética de alta resolución, debería ser empleada como estudio diagnóstico complementario junto a la clínica y exámenes electrofisiológicos, en los pacientes con sospecha de neuralgia del NP.

The pudendal nerve entrapment is an entity understudied by diagnosis imaging. Various causes are recognized in relation to difficult labors, rectal, perineal, urological and gynecological surgery, pelvic trauma fracture, bones tumors and compression by tumors or pelvic pseudotumors. Pudendal neuropathy should be clinically suspected, and confirmed by different methods such as electrofisiological testing: evoked potentials, terminal motor latency test and electromyogram, neuronal block and magnetic resonance imaging. The radiologist should be acquainted with the complex anatomy of the pelvic floor, particularly on the path of pudendal nerve studied by magnetic resonance imaging. High resolution magnetic resonance neurography should be used as a complementary diagnostic study along with clinical and electrophysiological examinations in patients with suspected pudendal nerve neuralgia.

Pudendal Nerve Entrapment Syndrome due to a Ganglion Cyst: A Case Report

Pudendal nerve entrapment syndrome is an unusual cause of chronic pelvic pain. We experienced a case of pudendal neuralgia associated with a ganglion cyst. A 60-year-old male patient with a tingling sensation and burning pain in the right buttock and perineal area visited our outpatient rehabilitation center. Pelvis magnetic resonance imaging showed the presence of multiple ganglion cysts around the right ischial spine and sacrospinous ligament, and the pudendal nerve and vessel bundle were located between the ischial spine and ganglion cyst at the entrance of Alcock's canal. We aspirated the lesions under ultrasound guidance, and consequently his symptoms subsided during a 6-month follow-up. This is the first report of pudendal neuralgia caused by compression from a ganglion cyst around the sacrospinous ligament.

Bloqueo de nervios pudendos guiados por radioscopía. Presentación de caso clínico / Blocking of pudendal nerves guided by fluoroscopy. Presentation of clinical case

La neuralgia del nervio pudendo es un cuadro doloroso neuropático poco frecuente enmarcado dentro de los sindromes de Dolor Pélvico Crónico, caracterizado por dolor perineal que aumenta con la posición sentada. Esta entidad es de difícil tratamiento, no habiendo consenso sobre el abordaje más eficaz para aliviar el dolor. Los bloqueos de los nervios pudendos juegan un rol en el diagnóstico de la enfermedad así como en el abordaje intervencionista cuando es refractaria al tratamiento conservador. Se describe un caso clínico de un paciente de sexo masculino, con diagnóstico clínico de neuralgia del pudendo bilateral, refractaria al tratamiento farmacológico, en el cuál se practicaron bloqueos de los nervios pudendos con criterio diagnóstico y terapéutico. Se utilizó para ello una técnica guiada con radioscopia, en posición decúbito ventral, por vía transglútea. Se utilizó bupivacaína al 0.5% sin esteroides asociados. Estos bloqueos obtuvieron un alivio del dolor mayor a un 50% por 4 a 6 semanas debiendo ser repetidos en 3 oportunidades. En un intento de lograr alivio de mayor duración se realizó una radiofrecuencia pulsada de los pudendos, sin respuesta analgésica efectiva. Se concluye que los bloqueos de los nervios pudendos con anestésicos locales pueden ser útiles en el tratamiento integral de la neuralgia del pudendo. La radiofrecuencia pulsada del nervio debe ser más estudiada.

Block of pudendal nerves guided by radioscopy. Clinical case presentation. The pudendal nerve neuralgia is a rare neuropathic painful picture framed within Chronic Pelvic Pain syndromes characterized by perineal pain that increases with the sitting position. This condition is difficult to treat, there being no consensus on the most effective approach to relieve pain. Blockages of the pudendal nerves play a role in disease diagnosis as well as the interventional approach when it is refractory to conservative treatment. It is described a case of a male patient with clinical diagnosis of bilateral pudendal neuralgia refractory to drug therapy, in which the pudendal nerve blocks were performed with diagnostic and therapeutic criteria. We used to do a technique guided fluoroscopy/radioscopy in ventral decubitus position, via transglútea. We used 0.5% bupivacaine without associated steroids. These blocks obtained greater pain relief at 50% for 4 to 6 weeks must be repeated on 3 occasions. In an attempt to achieve longer-lasting relief from a pulsed radiofrequency pudendal performed without effective analgesic response. We conclude that the pudendal nerve blocks with local anesthetics may be useful in the comprehensive treatment of pudendal neuralgia. The pulsed radiofrequency nerve should be studied further.

Ultrasound-guided pudendal nerve pulsed radiofrequency in patients with refractory pudendal neuralgia: Three cases report

Pudendal neuralgia is characterized by severe sharp pain along the innervation area of pudendal nerve, which may be worsened when sitting position. Successful pudendal nerve block is crucial to the diagnosis of pudendal neuralgia. Although fluoroscopy-guided pudendal nerve blocks have traditionally been performed, recently ultrasound-guided pudendal nerve blocks were reported. For the long term effect of nerve block, pulsed radiofrequency was performed under fluoroscopic guidance in some reports. We report our successful experiences of three cases using ultrasound-guided pulsed radiofrequency.

Infiltración de nervio pudendo guiada por tomorafía axial computada, por vía transglútea: terapia frente al dolor ocasionado por neuralgia del nervio pudendo / Transgluteal computed tomography-guided infiltration of the pudendal nerve: therapy for pain caused by neuralgia of the pudendal nerve

ANTECEDENTES: La neuralgia del nervio pudendo pocas veces es sospechada y menos diagnosticada. Por esta razón, las pacientes que la padecen, consultan múltiples veces antes de llegar a un diagnóstico definitivo. OBJETIVO: Revisar la seguridad y eficacia de la infiltración de nervio pudendo, en el tratamiento del dolor en pacientes con neuralgia del nervio pudendo. MÉTODO: Seguimiento prospectivo de cinco pacientes ingresadas bajo el diagnóstico de síndrome de atrapamiento del nervio pudendo. La edad media de las pacientes fue 45 años. Debían tener 2 criterios mayores o 1 criterio mayor asociado a 2 criterios menores. Dolor con al menos 6 meses de evolución. Sin tratamientos previos. A todas se les realizó encuesta de síntomas y signos de atrapamiento del nervio pudendo. Todas fueron infiltradas con corticoides y anestésico, guiada por tomografía axial computada. Se comparó el dolor antes y después de la infiltración con escala de 0 a 10. RESULTADOS: No hubo complicaciones durante el procedimiento. Todas disminuyeron el dolor después de la infiltración, y señalaron estar conformes con los resultados. CONCLUSIÓN: La infiltración del nervio pudendo guiada por tomografía axial computada, es una técnica segura y eficaz, en el control o disminución del dolor pelviano, ocasionado por neuralgia del nervio pudendo. Sólo el seguimiento permitirá evidenciar la mantención de los buenos resultados, o la necesidad de repetir la infiltración o de realizar cirugía de descompresión.

BACKGROUND: The pudendal neuralgia infrequently is suspected and diagnosed. Therefore the patients who suffer it consult manifold times before arriving at a definitive diagnosis. OBJECTIVE: To review the security and effectiveness of the pudendal nerve infiltration in the pudendal neuralgia treatment. METHOD: Prospective study of five patients under entrapment pudendal nerve syndrome diagnosis. The media age was 45 years old. All patients must have 2 greater criteria or 1 greater criteria associate to 2 smaller criteria. The pain must have an evolution of at least 6 months. They must not have antecedent of infiltration or surgery like treatment of this syndrome. A questionnaire of entrapment pudendal nerve syndrome was applied. The infiltration was with corticoids and anesthetic guided by CT scan. The patients classified their pain with a subjective scale; in which 0 is the pain absence and 10 is the maximum pain. The pain was compared before and after infiltration. RESULTS: Complication did not appear during the infiltration procedure. In one patient an asymmetry in the spine corresponding to the side of pain was observed. All patients diminished the pain after the infiltration. All indicated to be in agreement with the results. CONCLUSION: The pudendal nerve infiltration guided by CT scan is safe and effective technique in the treatment or diminish of the pudendal neuralgia. Only the follow-up will allow demonstrating the good results, or the necessity to repeat the infiltration, or the necessity of decompression surgery.

Predictors of Outcome Following Anterior Sphincter Repair in Obstetric Fecal Incontinence

PURPOSE: This study was designed to evaluate the outcome of anterior sphincter repair and factors influencing the outcome in patients with obstetric fecal incontinence. METHODS: Thirty-three patients undergoing sphincter repair for obstetric fecal incontinence were prospectively evaluated. Preoperatively, standardized interviews and physiologic studies were performed. The severity of incontinence was graded according to the Parks' classification. Patients' satisfaction was classified as excellent, good, fair, and no improvement. An anterior overlapping sphincteroplasty was performed with or without levatorplasty. Interviews and manometry were repeated three months after the operation. Four years after the operation, the severities of incontinence and patients' satisfaction were reevaluated. RESULTS: Preoperatively, all patients showed high-grade incontinence (grade 3 or 4). Three months after the operation, 28 patients (84.8%) had successfully recovered continence (incontinence grade 1 or 2), and 25 of those patients (75.8%) replied with satisfaction (excellent or good). The maximal average squeeze pressure (MASP) and the high-pressure zone (HPZ) length, but not the maximal average resting pressure (MARP), had significantly increased in patients with successfully recovered continence. At the 4-year follow ups, the outcomes were significantly worse than thase at 3 months, but 24 patients (72.7%) still maintained good outcome, and 25 patients (66.7%) still replied with satisfaction that was not significantly worse than that at 3 months. Patients with a young age (<45 years), a shorter duration of incontinence (<10 years), a larger increase in MASP or MASP at 3 months after the operation, no pudendal neuropathy, and a good result at 3 months were more likely to maintain low-grade incontinence. The addition of levatorplasty and an increase in the HPZ length at 3 months did not affect the outcome. CONCLUSIONS: At the 4-year follow-ups, the outcomes had significantly deteriorated, but patients' satisfaction had not. Age, the duration of incontinence, a postoperative increment in MASP or MASP, pudendal neuropathy, and a short-term good outcome were closely related to the long-term outcome.

Methodology of Evaluating the Function of Pudendal Nerve

PURPOSE: Although the pudendal nerve terminal motor latency (PNTML) is normally used, there is no definite test that accurately reflects the function of the pudendal nerve. This study was undertaken to determine the relative accuracy of the various methods in measuring the function of the pudendal nerve. METHODS: Thirty one female patients (age 51.3+/-15.7) with a defecation disorder (constipation 20, fecal incontinence 11) were evaluated prospectively using a neurophysiologic test and balloon reflex manometry. Five parameters such as the right and left PNTML, anal mucosal electrosensitivity, latency and the amplitude of the rectoanal contractile reflex (RACR) were analyzed statistically for their correlation. RESULTS: There was no significant inter-test correlation among the parameters. However, the intra-test correlations between the parameters such as the right and left PNTML (r=0.9629, P<0.001)/latency and the RACR amplitude (r= -0.3770, P=0.0366) were found to be significant. CONCLUSION: The accuracy of these tests in evaluating the pudendal neuropathy could not be determined. However, because it can be assumed that a measurement of the RACR in addition to RNTML is technically accurate, it there will need to be more study for it to be used as an alternative to a PNTML measurement.

Etiology and Surgical Management of Fecal Incontinence

Fecal incontinence is a disabling condition with devastating psychosocial impact due to diverse etiology. This study was performed to assess various causes of fecal incontinence, clinical evaluation, and adequate surgical treatment. METHODS: Eighty patients presenting fecal incontinence during July 1989 and June 1997 were included. They were evaluated by clinical parameters and physiologic tests including the defecography, electromyography, transanal ultrasonography, and anorectal manometry. Surgery was performed in 31 patients based on those evaluation. Pre- and post-operative comparison of manometric findings, clinical assessment, incontinence score, and the outcome of surgery were assessed. Mean postoperative follow-up was 22 (2~84) months. RESULTS: Inappropriate anal surgery was the most common cause, and then injuries during delivery, trauma, rectal prolapse, and hysterectomy in descending order. Defecography was performed in 21 patients and mean values of anorectal angles were 115+/-15degrees at rest, 98+/-18degrees during squeezing, and 136+/-10degrees during push. Electromyography was performed in 8 patients showing pudendal neuropathy in 2, bilateral lumbosacral polyradiculopathy in 4, and normal finding in 2 patients, respectively. Transanal ultrasonography was performed in 33 patients and 22 among them showed finding of an injury of the anal sphincters. Surgery was performed in 31 patients due to anal sphincter damage, rectovaginal fistula, and anal stricture in descending order. Type of surgery was determined by respective cause: plication, triple repair (sphincteroplasty, anoplasty, perineorrhaphy), and posterior rectopexy in descending order. Nerve preserving graciloplasty was performed in a 12 year-old girl who had severe defect of the anal sphincters by traffic accident, showing sound recovery with a good functional outcome. Although there was no significant difference of manometric variables between pre- and post-operative periods, sphincter length, and maximum resting and squeezing pressure, revealed an increasing tendency postoperatively. According to the clinical assessment between pre- and post-operative periods, urgency to evacuate, soiling, sensation on defecation, and quality discrimination were significantly improved postoperatively (P<0.01). Incontinence score was markedly decreased from 10.6+/-6.1 during preoperative period to 2.9+/-4.7 during postoperative period (P<0.01). Eighty one percent of the patients undergone surgery experienced a significant symptomatic improvement. CONCLUSIONS: According to the analysis of the causes of fecal incontinence, inappropriate anal surgery, injuries during delivery, and trauma were main causes. Adequate application of physiologic tests, such as, defecography, electromyography, transanal ultrasonography, and anorectal manometry, were helpful in determining treatment modality and types of surgery. We got satisfactory results with adequate surgery based on the physiologic tests.

Sphincter Repair for Fecal Incontinence after Obstetric Injury

PURPOSE: We designed this study to evaluate efficacy of sphincter repair and factors influencing in patients with postobstetric fecal incontinence. METHODS: Twenty-one patients (mean age 42 years; range 23~67) undergoing sphincter repair for postobstetric fecal incontinence (mean duration 12 years; range 6 months~46 years) were evaluated prospectively. Preoperatively, standardized interviews, anorectal manometry and measurement of pudendal nerve terminal motor latency (PNTML) were performed. Incontinence was graded according to the Parks' classification: Grade 1 - continence to stool and flatus; Grade 2 - incontinent to flatus, some urgency to stool present but no incontinence; Grade 3 - incontinent to liquid stool; Grade 4 - incontinent to formed stool. Sphincter repair methods were overlap repair of external anal sphincter (EAS) in 4 patients, overlap repair of EAS with anterior levatorplasty in 15 patients, and overlap repair of EAS with anterior levatorplasty and postanal repair in 2 patients. Anorectal manometry at 3 months, and interviews at 3 months and 6 months after sphincter repair were performed again. Patients' satisfaction was classified as excellent, good, fair, and no improvement. RESULTS: Difficulty in first delivery was noticed in 18 patients and history of previous sphincter repair was noticed in 5 patients. Preoperatively, most patients showed high grade incontinence (grade 3 in 13 and grade 4 in 8 patients). After sphincter repair, 18 patients (85.7%) became grade 1 or 2, and 16 patients (76.2%) replied their functional satisfaction excellent or good. There were no difference between the results at 3 months and 6 months. Poor functional outcome was in 2 of 3 patients with bilaterally prolonged preoperative PNTML. Short duration of incontinence and young age at the time of repair favored good results. Previous sphincter repair did not influence the outcome. Postoperatively both anal pressure and high pressure zone length were significantly increased in patients with improved continence Postoperative complications were wound infection in 2 patients and necrosis at the apex of the advancement skin flap in 1 case but these did not influence the outcome. CONCLUSIONS: Most postobstetric fecal incontinence can be successfully treated with sphincter repair. Excellent results are expected when the duration of incontinence is short and the patients are young. Pudendal neuropathy seemed to be related to poor 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.

Defecographic Findings in Patients with Fecal Incontinence

We performed this study to investigate defecographic findings in patients with fecal incontinence and to compare these findings with age-matched asymptomatic controls. Twenty patients with fecal incontinence and 20 asymptomatic subjects were included. Videodefecography and pelvic electrophysiologic test were performed. There were no significant differences on the presence of rectal wall changes such as rectocele, mucosal prolapse, or incomplete evacuation, but intussusception was more common in patients group. The anorectal angle were 112.8+/-16.2degrees, 93.0+/-15.0degrees, 118.8+/-16.3degrees at resting, squeezing, and straining, respectively in controls, whereas 121.5+/-20.8degrees, 110.8+/-22.2degrees, 132.0+/-21.1degrees, respectively in patients group. There were significant differences of anorectal angle at squeezing and straining in patients group compared with controls(p< 0.05). Perineal descent was significantly decreased at squeezing in patients group compared with controls(p<0.05). Anal canal width was signi(icantly widened in patients group compared with controls(p<0.05). There were no differences in various defecographic parameters depending on the presence of pudendal neuropathy. In conclusion, defecographic findings in fecal incontinence showed more obtuse anorectal angle, poorer perineal descent at squeezing, and widening of anal canal.