The impact of delivery on anorectal function in women with and women without anal incontinence--a prospective study.

A prospective study was carried out to evaluate the effect of delivery on anal physiological parameters in anally incontinent women (n=18) compared with continent women (n=42). Perineal plane, anal manometry, anal mucosa electrosensitivity and pudendal nerve terminal motor latency (PNTML) were all assessed at 26 weeks' gestation and at 3 and 6 months after delivery. No major effect on the incremental changes in anal physiological parameters was seen from 26 weeks of gestation to 3 months after delivery. At 26 weeks of gestation perineal plane and maximal squeeze pressure were impaired in incontinent women (P=0.02 and P=0.06); PNTML was impaired in incontinent women 6 months after delivery (P=0.05). Irrespective of continence status, delivery had an adverse effect on maximal squeeze pressure and PNTML. No major incremental changes were found between incontinent and continent women after delivery. However, there was a tendency to a higher degree of impairment of maximal squeeze pressure among incontinent women. Delivery per se had an adverse effect on maximal squeeze pressure and PNTML irrespective of continence status.

Comparison of methods used for measurement of rectal compliance.

INTRODUCTION: Compliance is defined as the change in volume or cross-sectional area divided by the change in pressure. Pressure-volume measurement during distention with a compliant balloon is the most commonly used method for computation of rectal compliance. However, intraindividual and interindividual variations are large, restricting the usefulness of the method. Other methods such as rectal distention by a large, noncompliant bag and rectal impedance planimetry for assessment of pressure-cross-sectional-area relations have been proposed as alternatives owing to the reduction of errors from elongation of the balloon within the rectal lumen. However, in vivo reproducibility of pressure-volume measurement during distention with a compliant balloon, pressure-volume measurement during rectal distention by a large, noncompliant bag, and rectal impedance planimetry have never been compared. PURPOSE: The aim of this study was to compare in vivo reproducibility of the above-mentioned methods and to study their in vitro reproducibility and validity. METHODS: Ten healthy volunteers (six men) aged 21-59 years were randomized to either rectal pressure-volume measurement with a compliant balloon or rectal impedance planimetry. After a one-hour rest, the other procedure was performed. After two weeks, both procedures were again performed in the same order. During rectal impedance planimetry the volume of the bag used (maximum volume 450 ml; secured at both ends to the probe) was continuously registered, measuring pressure-volume relations during rectal distention by a large, noncompliant bag. Reproducibility was tested by comparing the difference divided by the mean for each method at eight pressure steps in the range from 5 to 40 cm H2O. Furthermore, the in vitro reproducibility and validity of the three methods were studied using polyvinyl chloride tubes with known cross-sectional areas. RESULTS: In vivo reproducibility for pressure-volume measurement with a large, noncompliant bag and rectal impedance planimetry was significantly better than for pressure-volume measurement with a compliant balloon (P = 0.005 and P = 0.019, respectively). No statistically significant difference was found between pressure-volume measurement with a large, noncompliant bag and rectal impedance planimetry (P = 0.20). In vitro reproducibility of pressure-volume measurement with a large, noncompliant bag and rectal impedance planimetry was good, but some elongation occurred, reducing the validity of pressure-volume measurement with a large, noncompliant bag. Coiling and elongation of the balloon within the lumen were major sources of error for pressure-volume measurement with a compliant balloon. CONCLUSION: In vivo and in vitro reproducibility of methods used for measurement of rectal compliance can be improved by restricting the effects of elongation within the lumen either by using a large-volume, noncompliant bag or by rectal impedance planimetry. However, pressure-volume measurement will to some degree depend on the properties of the balloons or bags.

Pad testing in incontinent women: a review.

This article reviews the literature on pad-weighing tests used for objectifying and quantifying incontinence in urinary incontinent women. The patients wear pads weighed before and after the test period. A weight gain is taken as a measure of the amount of urine loss. The tests are in principle of two different types: short-term office tests and long-term home tests, and measure different aspects of urinary control and dysfunction. Both have an inherent large intra- and interindividual variability. Pad weight gains obtained from patients referred for incontinence and those from self-reported continent controls overlap to a certain degree, and it is not possible to identify distinct numerical cut-off values separating continence from incontinence. This suggests that incontinence is a complex condition in which the amount of leakage, other sources of weight gain, and differences in the individual patients' personal characteristics influence the identification and quantification of the problem. In spite of the shortcomings the pad tests remain a valuable tool for both the clinician and the researcher. The home pad tests are superior to the office tests in terms of authenticity, and should be performed with a concomitant systematic registration of the participant's voidings, fluid intake and episodes of incontinence.

[The effect of parity on anorectal function]. / Paritetens betydning for analfysiologisk funktion hos kvinder.

An observational study of 144 (mean age 50 [range 45-57] years) perimenopausal women randomly selected from the National Register was conducted in order, to study long term effects of vaginal deliveries on anorectal function. The mean number of vaginal deliveries was two (range 0-6). Measurements were perineal position at rest and during straining, anal mucosa electrosensitivity, maximum resting pressure, maximum squeeze pressure of the anal sphincters, and pudendal nerve terminal motor latency. All tests were performed by a single investigator (AMR) who had no knowledge of the subject's parity. Increasing parity correlated with a lowered perineal position at rest (correlation coefficient (r) = 0.26, p = 0.003) and during straining (r = 0.24, p = 0.006), an increased threshold of anal sensibility (r = 0.22, p = 0.008), and an increased pudendal nerve terminal motor latency (r = 0.27, p = 0.002). No effect of parity on the maximum resting pressure (r = 0.06, p = 0.70) and maximum squeeze pressure (r = 0.06, p = 0.36) was found. The number of vaginal deliveries only accounted for a minor fraction of the total variability (between 3.6-5.7%). It is concluded that repeated vaginal deliveries have a long term adverse effect on anorectal function in a population of randomly selected healthy perimenopausal women.

No correlation between perineal position and pudendal nerve terminal motor latency in healthy perimenopausal women.

BACKGROUND: Significant associations between perineal descent and pudendal nerve latency have previously been described in fecally incontinent patients. This has led to the hypothesis that pelvic floor muscle and nerve injury initiated by childbirth might progress and cause fecal incontinence. PURPOSE: The study contained herein was undertaken to test whether changes in perineal position and pudendal nerve latency were associated in a population of healthy middle-aged women. METHODS: A cross-sectional study of 144 women were selected randomly from the Danish National Register; they had a mean age of 50 (range, 45-57) years and a mean parity of 2 (range, 0-6). Perineal position at rest and during simulated defecation and pudendal nerve terminal motor latency were measured. All examinations were performed by one of the authors (AMR) and without the knowledge of parity. RESULTS: The perineal position both at rest and during straining was significantly lowered, and the pudendal nerve terminal motor latency was significantly prolonged with increasing numbers of vaginal deliveries (data not shown). There was, however, no association between pudendal nerve terminal motor latency and perineal position at rest (correlation coefficient, r = -0.15, P = 0.1) or during simulated defecation (r = -0.08, P = 0.4). CONCLUSION: Small but significant effects of vaginal deliveries were detected in a random population of healthy perimenopausal women. However, because perineal descent and pudendal nerve latency were not associated, our findings do not support the hypothesis that damage induced by vaginal delivery to the pudendal nerves and pelvic floor will progress.

No relationship between subjective assessment of urinary incontinence and pad test weight gain in a random population sample of menopausal women.

PURPOSE: We studied the association between urinary incontinence and pad weight gain during a 24-hour pad test in healthy menopausal women. MATERIALS AND METHODS: Menopausal women 45 to 58 years old were randomly sampled from the national register. Information on self-reported urinary incontinence was collected at patient interview using a structured questionnaire. A 24-hour home pad test was performed and episodes of urinary incontinence during the pad test were noted. RESULTS: A total of 144 women 45 to 57 years old (mean age 50) were included in the study. At the interview 99 subjects (69%) reported urinary continence and 45 (31%) reported incontinence. Of the continence group 78 women (80%) performed the pad test and the mean weight gain was 3.1 gm. (range 0 to 9). Of the incontinence group 38 women (84%) performed the pad test and the mean weight gain was 3.3 gm. (range 0 to 8, not significant). Of the 38 women in the incontinence group 16 reported 1 or more episodes of urinary incontinence, whereas the remaining 22 reported no incontinence during the pad test. There was no difference in pad weight gain between these 2 groups (mean gain 3.3 gm., range 0 to 8). CONCLUSIONS: The subjective assessment of urinary incontinence was frequent but it was not associated with the objective findings of the 24-hour pad test.

Age and anorectal sensibility in normal women.

BACKGROUND: Our aim was to study associations between age and anorectal sensibility in healthy women. METHODS: Seventy-five women, with a mean age of 50 (range, 20-83) years, and mean parity of 2 (range, 0-4), were studied. Anal mucosa electrosensitivity (AME) was measured 1 and 2 cm from the anal verge. Rectal sensibility was also measured (minimum perceived volume (MPV), desire to defaecate (DD), and urgency (U)). Associations between anorectal sensibility and age were corrected for parity by using multiple regression analysis. RESULTS: Threshold values of AME increased with age (P = 0.03) (1 cm) and P = 0.01 (2 cm)). Rectal sensibility threshold values were also positively associated with age (MPV, P = 0.003; DD, P = 0.04; and U, P = 0.06). Changes in AME were greater after menopause, whereas associations between rectal sensibility and age seemed linear. CONCLUSION: Impairment of the anorectal sensibility appears to be part of the normal ageing process, thus increasing the risk of faecal incontinence in old women.

Test-retest repeatability of anorectal physiology tests in healthy volunteers.

PURPOSE: This study was undertaken to evaluate repeatability of tests of anorectal function in 58 healthy female volunteers, mean age 50 (range, 45-57) years. METHODS: Participants were studied on two separate occasions by one investigator in one laboratory using the same equipment. RESULTS: Mean difference for perineal position was 0.1 (95 percent confidence interval, -0.1-0.3) cm, and for perineal descent it was 0.02 (-0.2-0.3) cm. For anal mucosa electrosensitivity, mean difference was -0.1 (-0.4-0.1) mA, for maximum anal resting pressure it was 2.2 (-3.5-7.8) cm H2O, for maximum anal squeeze pressure it was -1 (-6.5-4.5) cm H2O, and for pudendal nerve terminal motor latency it was 0.04 (-0.02-0.09) msec. Coefficients of variation varied from 8 percent for pudendal nerve terminal motor latency to 49 percent for perineal descent. CONCLUSION: There was no systematic variation in repeated measurements for any of the parameters studied; however, the nonsystematic variation was generally large.

Effects of age on anal function in normal women.

PURPOSE: To study effects of age on anal function in healthy women. METHODS: A study of 75 women with no known anorectal disease, aged 20 to 83 (mean 50) years, mean parity 2 (range 0-4). Perineal position at rest (PR), descent during straining (PS), maximum resting pressure (MRP) maximum squeeze pressure (MSP) of the anal sphincters, and pudendal nerve terminal motor latency (PNTML) were measured. Data were analysed using the multiple regression technique including age and parity in the model. RESULTS: Increasing age was significantly associated with a weakening of anal function. PR and PS were both lowered (P < 0.0001 and P = 0.0001). Anal sphincter pressures were reduced (MRP: P = 0.004, MSP: P = 0.015), and age was associated with an increased mean PNTML (P < 0.0001). All associations seemed to be linear. Parity was associated with a lowering of both PR and PS but not with the other parameters. Age accounted for 13-44% of the total variability seen in the tests of pelvic floor function. CONCLUSION: Age leads to a consistent reduction in anal function and this is likely to increase the risk of faecal incontinence in old age. From the current data we suggest that in normal women with an uncomplicated obstetric history increasing age is associated with significant changes in anal function whereas long-term effects of vaginal deliveries play a minor role. Moreover our results suggest gradual changes throughout adult life, rather than large changes occurring after menopause.

Long-term effect of vaginal deliveries on anorectal function in normal perimenopausal women.

PURPOSE: This study was undertaken to determine the long-term effects of vaginal deliveries on anorectal function in healthy perimenopausal women. METHODS: An observational study of 144 perimenopausal women living in the county of Aarhus, Denmark, aged 45 to 57 (mean, 50) years were randomly selected from the National Register. All women had delivered 0 to 6 (mean, 2) times 10 to 34 years before the investigation. Examinations describing pelvic floor function were measurements of perineal position at rest and descent during straining, anal mucosa electrosensitivity, maximum resting pressure and maximum squeeze pressure of the anal sphincters, and pudendal nerve terminal motor latency. All tests were performed by one of the authors (AMR) and without knowledge of parity. Data were analyzed using the multiple regression technique, and all associations between anorectal function and parity were corrected for age and hysterectomy status. RESULTS: Increasing parity correlated with a lowered perineal position at rest (correlation coefficient (r) = 0.26; P = 0.003), an increased descent during straining (r = 0.24; P = 0.006), an increased threshold of anal mucosa electrosensitivity (r = 0.22, P = 0.008), and an increased pudendal nerve terminal motor latency on both sides (r = 0.27; P = 0.002). No effect of parity of the maximum resting pressure (r = 0.06; P = 0.70) and maximum squeeze pressure (r = 0.06; P = 0.36) was found. The number of vaginal deliveries account for only a minor fraction of the total variability seen in the tests of pelvic floor function (between 1.6 and 5.7 percent). CONCLUSION: Repeated vaginal deliveries have a long-term adverse effect on anorectal physiology in a population of randomly selected healthy perimenopausal women.

Multiple vaginal deliveries increase the risk of permanent incontinence of flatus urine in normal premenopausal women.

PURPOSE: This study was undertaken to evaluate the risk of permanent flatus or urinary incontinence after repeated vaginal deliveries. METHODS: In 1989 a questionnaire on obstetric history and urinary and fecal incontinence was sent to a sample of 304 women selected from the birth records from 1976 to 1988; 242 responded (80 percent). RESULTS: Participants had one, two, or three vaginal deliveries, all without an obstetric tear of the anal sphincter. After the first, second, and third deliveries, 1.2, 1.5, and 8.3 percent developed permanent flatus incontinence. The risk was significantly increased after the third delivery compared with the first and second deliveries (odds ratio, 6.6; confidence interval, 2.4-18.3). Permanent urinary incontinence after the first, second, and third delivery developed in 3.3, 1.0, and 6.8 percent. The risk was significantly increased after the third delivery compared with the first and second (odds ratio, 3.2; confidence interval, 1.1-9.1). CONCLUSION: These results indicate that repeated vaginal deliveries increase the risk of minor anal and urinary incontinence, which were found to be a common problem in premenopausal women.