Pudendal nerve function in idiopathic fecal incontinence.

PURPOSE: The study was undertaken to determine whether idiopathic fecal incontinence in middle-aged and elderly females is likely to be a result of pudendal nerve damage (neurogenic incontinence) or merely a consequence of aging. METHODS: One hundred seventy-eight females over the age of 50 years with fecal incontinence were studied. The incontinence was classified as idiopathic because none of the patients related the incontinence to trauma (including obstetric trauma) or other events or diseases. All had an anal physiology examination, including determination of nerve conduction velocity of both pudendal nerves (pudendal nerve terminal motor latency). RESULTS: With a cutoff value of 2.4 msec, 79 percent (95 percent confidence limit, 73-85) had normal pudendal nerve terminal motor latency on both sides, 13 bilaterally prolonged latency (7 percent; 4-11), and 25 unilaterally prolonged latency (14 percent; 9-19). With a cutoff value of 2.2 msec, 66 percent (59-73) had normal latency on both sides, 15 percent (9-20) bilaterally prolonged pudendal nerve terminal motor latency, and 20 percent (14-26) unilateral prolongation. No relationship between the groups with normal, bilateral, or unilateral prolongation of pudendal nerve terminal motor latency and anal resting and squeeze pressure was found. Anal resting pressure decreased with increasing age (P < 0.05). CONCLUSION: Our data support the view that idiopathic fecal incontinence in the majority of females is likely to be a result of the aging process and that only a limited number may suffer from anal incontinence of neurogenic origin. Furthermore, unilateral prolongation of pudendal nerve terminal motor latency probably is without clinical significance.

[Anal and urinary incontinence after obstetric anal sphincter rupture]. / Anal- og urininkontinens efter obstetrisk analsphincterruptur.

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.

Vaginal pudendal nerve stimulation: a new technique for assessment of pudendal nerve terminal motor latency.

BACKGROUND: To evaluate vaginal stimulation of the pudendal nerve, a new method for investigation of pudendal nerve terminal motor latency (PNTML) and to assess the reproducibility of the method. METHODS: Thirteen healthy women and 11 female patients, median age 31 years (range 21-53 years), participated in the study. Ten patients had sustained an anal sphincter rupture and one had idiopathic anal incontinence. Pudendal nerve terminal motor latency was measured after vaginal stimulation of the pudendal nerve with motor response from the pelvic floor and rectal stimulation with motor response from the anal sphincter using the St. Marks pudendal electrode. The women were stimulated by two observers both vaginally and by the rectum. RESULTS: Vaginal PNTML for observer 1 was 2.06 msec (0.50 msec, 2 s.d.) and 2.04 msec (0.55 msec, 2 s.d.) for observer 2, while rectal PNTML was 1.99 msec (0.56 msec, 2 s.d.) and 1.97 msec (0.54 msec, 2 s.d.) respectively. The difference between vaginal and rectal PNTML was 0.065 msec for observer 1 (p = 0.106) and 0.070 msec for observer 2 (p < 0.05). Degree of agreement between vaginal and rectal PNTML was 80%-116% for observer 1 and 84%-12% for observer 2 (100% represent total agreement between measurements). Interobserver reproducibility for vaginal PNTML was 90%-109% and 86%-113% for rectal PNTML. CONCLUSION: In clinical practice vaginal PNTML may replace rectal PNTML in women. Reproducibility is in the same range as for rectal PNTML.

Delivery and pudendal nerve function.

OBJECTIVE: To assess the impact of mode of delivery and the occurrence of pelvic instability upon the pudendal nerve function and relate the pudendal nerve function to the occurrence of anal and urinary incontinence. METHODS: One hundred and forty-six pregnant women were examined during pregnancy and 12 weeks post partum with measurement of pudendal nerve terminal motor latency (PNTML), the difference between the two measurements was defined as delta PNTML. Anal and urinary continence status, details of delivery and the occurrence of pelvic instability were recorded prospectively. RESULTS: Pudendal nerve terminal motor latency increased from 1.7 msec in primiparae and 1.8 msec in multiparae during pregnancy to 2.0 msec (p < 0.001) and 2.1 (p < 0.001) respectively after delivery. The increase was significantly higher after the use of vacuum extraction (p < 0.04). Multivariate analysis showed that delta PNTML was associated with age, the presence of pelvic instability and the use of vacuum extraction. Whereas delta PNTML was not associated with factors such as infant's head circumference and weight, parity, cesarean section, pudendal block, epidural analgesia and second stage of labor. Only four women had anal incontinence after delivery. Twenty-five women with urinary incontinence had a significantly higher mean PNTML (2.20 msec) than 121 continent women (2.01 msec). CONCLUSION: Pudendal nerve terminal motor latency increases in both primiparous and multiparous women after delivery. In 10% of the women the increase resulted in a pathologic PNTML value > 2.4 msec. The delta PNTML was significantly associated with age, the occurrence of pelvic instability and the use of vacuum extraction. The group of women with urinary incontinence had a significant increased PNTML.

Pudendal nerve function during pregnancy and after delivery.

The aim of the study was to assess pudendal nerve function serially during pregnancy and after delivery. Twenty-eight women participated at 14, 30 and 36 weeks of pregnancy and 12 weeks postpartum. A prospective study of pudendal nerve terminal motor latency during pregnancy and after delivery was carried out. Results showed that pudendal nerve terminal motor latency did not increase significantly during pregnancy but increased significantly after delivery.

Reliability of pudendal nerve terminal motor latency.

AIM: To evaluate reliability of Pudendal Nerve Terminal Motor Latency (PNTML). METHODS: Forty healthy subjects, 24 women and 16 men, and eight female patients were included. Four patients had idiopathic faecal incontinence and 4 an anal sphincter rupture after child-birth. PNTML measurement was performed by two observers with the patient in left lateral and supine position. Examinations were repeated on another day to evaluate intraindividual reproducibility. RESULTS: Interobserver reproducibility was 92%-116% for PNTML. Degree of agreement for PNTML between left lateral and supine position was 86%-111%. Intra-individual reproducibility in the supine and left lateral positions was 89%-109% and 88%-113% respectively. Normal values for mean PNTML were higher in women compared with men, 1.91 msec (2 SD, 0.52 msec) and 1.74 msec (2 SD, 0.33 msec) respectively, t = 2.44, 37 DF, P < 0.01. CONCLUSIONS: Reliability of PNTML in terms of interobserver and intraindividual reproducibility was high. Women had higher normal values for PNTML than men.

Anal and urinary incontinence in women with obstetric anal sphincter rupture.

OBJECTIVE: To assess the long term impact of obstetric anal sphincter rupture on the frequency of anal and urinary incontinence and to identify factors to predict women at risk. DESIGN: An observational study. SETTINGS: Departments of Obstetrics and Gynaecology and of Surgery D, Glostrup County University Hospital, Denmark. PARTICIPANTS: Ninety-four consecutive women who had sustained an obstetric anal sphincter rupture. INTERVENTIONS: Assessment of history, anal manometry, anal sphincter electromyography and pudendal nerve terminal motor latency at three months postpartum A questionnaire regarding anal and urinary incontinence was sent two to four years postpartum. MAIN OUTCOME MEASURES: The frequency of anal and urinary incontinence and risk factors for the development of incontinence. RESULTS: Thirty of 72 women (42%) who responded had anal incontinence two to four years postpartum; 23 (32%) had urinary incontinence and 13 (18%) had both urinary and anal incontinence. Overall, 40 of 72 women (56%) had incontinence symptoms. The occurrence of anal incontinence was associated with pudendal nerve terminal motor latencies of more than 2.0 ms, and the occurrence of urinary incontinence was associated with the degree of rupture, the use of vacuum extraction and previous presence of urinary incontinence. Seventeen women had subsequently undergone a vaginal delivery in relation to which four (24%) had aggravation of anal incontinence, and three (18%) had aggravation of urinary incontinence. Of the women with incontinence, 38% wanted treatment but only a few had sought medical advice. CONCLUSIONS: Obstetric anal sphincter rupture is associated with a risk of approximately 50% for developing either anal or urinary incontinence or both. The prediction of women at risk is difficult. Information and routine follow up of all women with obstetric anal sphincter rupture is mandatory.

Assessment of lower urinary tract symptoms in women by a self-administered questionnaire: test-retest reliability.

A self-administered questionnaire assessing female lower urinary tract symptoms and their impact on quality of life is described and validated, on 56 females in six participating departments. The patients answered two identical questionnaires on separate occasions before treatment. Test-retest reliability of the questionnaire, correlation between the symptoms and their troublesomeness, and the reproducibility of this correlation were assessed. The percentage of mistakes in answers to each of the questions varied from 1.8% to 49.1%, mainly owing to missing answers in the item groups: appliances, sexual function and social activities. Test-retest showed a repeat frequency of 50.0%-91.0% for symptoms and 44.6%-82.1% for trouble. A highly significant positive correlation was found between symptoms and trouble, which was most pronounced for questions concerning pain and incontinence. This correlation was consistent within time. The primary validation of this questionnaire is good. Its relevance as a basis for medical priority and clinical decision making remains to be investigated.

Pudendal nerve recovery after a non-instrumented vaginal delivery.

The aim of the study was to investigate pudendal nerve function after a non-instrumented vaginal delivery. Seventeen primiparae women who had had a non-instrumented vaginal delivery were examined 3-5 days and 3 months after delivery. At both assessments pudendal nerve terminal motor latency (PNTML) was measured. The PNTML was found to decrease significantly from 2.64 ms in the first few days after delivery to 1.95 ms 3 months after delivery (P = 0.00009). PNTML decreased in all but one of the 17 women during the observation period. Immediately after delivery 9 women (53%) had a pathological high PNTML value, which was normalized 3 months later in all but 1. It was concluded that pudendal nerve function is often impaired immediately after a non-instrumented vaginal delivery, but recovers in most women over a 3-month period.

Pudendal nerve damage increases the risk of fecal incontinence in women with anal sphincter rupture after childbirth.

AIM: To evaluate anal function after childbirth in 94 women in whom sphincter rupture occurred and in 19 control women. The findings of anorectal physiological assessment and history of childbirth were related to the presence of fecal incontinence. METHODS: Anal manometry and electromyography were performed the first days after childbirth and repeated 3 months post partum together with measurement of pudendal nerve terminal motor latency. RESULTS: Eighteen patients (19%) presented with incontinence. None of the controls developed fecal incontinence after delivery. Anal manometry showed that both incontinent and continent patients had decreased resting and squeeze pressures compared to control subjects (p < 0.005). No difference in anal electromyography was found between the three groups. Both anal manometry and electromyography showed a significant increase in pressure and activity respectively 3 months after delivery in patients and controls. Patients with pudendal nerve terminal motor latencies > 2.0 milliseconds had an increased risk of having fecal incontinence compared to patients with pudendal nerve terminal motor latencies < or = 2.0 milliseconds (odds ratio 2.18, p < 0.05). Fecal incontinence could not be related to the weight or head circumference of the infant. The manometric and electromyographic findings, the use of pudendal nerve block, the length of the second stage of labor, the depth of rupture or the use of vacuum extraction could not be related to either fecal incontinence or pudendal nerve function. CONCLUSION: The manometric findings indicated damage to the anal sphincter apparatus in both continent and incontinent patients. Decreased pudendal nerve function characterized incontinent women. Accurate prediction of fecal incontinence in women with obstetric anal sphincter rupture is not possible.

[Sphincter rupture in the course of labor]. / Sphincterruptur i forbindelse med fødsel.

Thirty-eight women with anal sphincter rupture during childbirth were followed for three to 12 months. Fourteen patients presented with continence disturbances, nine to solid or fluid faeces and five to gas. Incontinence was present in nine patients three months after childbirth. Anal manometry and anal electromyography were performed on the patients three to five days after delivery and repeated at three, six and twelve months after childbirth. Manometry and electromyography were performed on 16 control subjects and 24 primiparous control patients who were investigated three to five days and three months after delivery. Anal manometry and anal electromyography showed significant differences between both incontinent and continent patients compared to control subjects and primiparous control patients. Primiparous control patients had decreased squeeze pressure as well as decreased electromyographic activity during the first days after delivery compared to control subjects. After three months no differences were found. Continence disturbances are frequent after sphincter rupture and these patients should be monitored after delivery and those with persisting incontinence offered sphincter repair.

Postpartum eclampsia. Impossible to eradicate?

Two cases of post partum eclampsia in previously healthy women are presented. Prior to the onset of eclamptic seizures, which occurred, one respectively eight days after delivery, the patients had no symptoms and were without signs of preeclampsia. Prevention of eclampsia is further discussed.

Dynamic anal manometry in the assessment of patients with obstructed defecation.

Patients with obstructed defecation show no consistent abnormalities when assessed by standard anorectal physiologic methods. With a recently developed technique for dynamic anal manometry, we studied 13 female patients with obstructed defecation and 20 healthy volunteers. Seven parameters of anal function were measured. There were no differences between the median values for the two groups. Seven patients (54 percent; 95 percent confidence limits, 25-81 percent) had anal compliance below the normal range, either during opening or closing of the sphincter at rest (five patients), during squeeze (one patient), or both (one patient). Opening and closing pressures of the sphincter at rest, maximal closing pressure during squeeze, and anal hysteresis were normal. Standard anal manometry did not show any differences between patients and controls. Rectal compliance was lower in patients with obstructed defecation, median difference 5 ml/cm H2O (95 percent confidence limits, 1-9 ml/cm H2O). In conclusion, the more detailed method of dynamic anal manometry shows that some patients with obstructed defecation have a less compliant anal sphincter and a less compliant rectum, but in many patients no abnormal findings can be made.

Sphincter rupture in childbirth.

Thirty-eight women with rupture of the anal sphincter occurring during childbirth were followed for 3-12 months. Nineteen had complete rupture of the external anal sphincter, 14 had a lesion involving more than half of the sphincter muscle and five had a superficial rupture. Fourteen patients presented with continence disturbances: nine to solid or liquid faeces and five to flatus. Incontinence was present in nine women 3 months after childbirth. Anal manometry and electromyography were performed in patients 3-5 days after delivery and repeated at 3, 6 and 12 months. Manometry and electromyography were also performed in 16 control subjects who were nulliparous or had given birth more than 2 years previously and 24 primiparous controls, who were investigated at 3-5 days and at 3 months. There were significant differences between both incontinent and continent patients compared with nulliparous and primiparous controls. Primiparous control subjects had decreased anal squeeze pressure as well as decreased electromyographic activity on the first days after delivery compared with nulliparous controls. After 3 months no differences were found. Continence disturbances are frequent after sphincter rupture; these patients should be monitored after delivery and those with persisting incontinence offered sphincter repair.

Physiological variation in rectal compliance.

The volume (V) of air inflated in a latex balloon placed in the rectum and the corresponding pressures (P) were measured in 48 subjects (24 men and 24 women) at three points: (1) earliest defaecation urge; (2) constant defaecation urge; and (3) maximum tolerable volume (MTV). The rectal pressures in all three cases were higher in men than in women. Woman aged over 60 years had higher rectal compliance (delta V/delta P) than men in the same age group, while no difference was found between men and women below the age of 60 years. Day-to-day variation of the measurements was tested in ten subjects. Reproducibility was good only for MTV (95 per cent confidence interval 57-183 per cent). Reproducibility of rectal compliance decreased with increasing values for this parameter. No such trend was found for the other parameters. In conclusion, MTV is a reproducible parameter and suitable for clinical use in evaluation of patients with faecal incontinence or constipation.

Dynamic anal manometry: physiological variations and pathophysiological findings in fecal incontinence.

A recently developed technique for dynamic anal manometry was used to study 40 healthy volunteers and 23 patients with fecal incontinence. Seven parameters of anal function were measured. Intraindividual variation of the parameters was studied in 5 females and 5 males. The results of dynamic anal manometry were compared with standard pull-through static anal manometry and correlated well. During opening of the anal sphincter at rest, compliance increased with increasing distension. Males had higher maximal closing pressures during squeeze and lower anal compliance during squeeze than females. There was no sex differences of the sphincter measurements at rest. Age had little effect, and gender had no effect on the measurements. With standard anal manometry, 6 of 23 patients with fecal incontinence both had maximal resting pressure and maximal squeeze pressure within the normal range. When dynamic anal manometry was used, all 23 patients showed one or more abnormal values. The method of dynamic anal manometry provides an opportunity for a more thorough assessment of anal sphincter function than previous manometric methods.

Viscous fluid retention: a new method for evaluating anorectal function.

The ability to retain viscous fluid in the standing position was tested in 22 patients with fecal incontinence, 11 patients with constipation, and 26 control subjects. Viscous fluid was introduced into the rectum in increments of 50 ml. The examination was stopped when the patient complained of discomfort or the viscous fluid leaked. Eighteen of 22 patients with fecal incontinence leaked fluid, while none of the control subjects and only four of the constipated patients did so. Patients with fecal incontinence retained significantly less viscous fluid than did control subjects, whereas no difference was found between patients with constipation and control subjects. Rectal sensation from distention with air was tested in the patients as well as in the control group. The following volumes and pressures at each sensation were measured: 1) earliest defecation urge (EDU), 2) constant defecation urge (CDU), and 3) maximum tolerable volume (MTV). Patients with fecal incontinence had lower volumes than control subjects at all sensations, while patients with constipation had higher volumes at earliest defecation urge and at constant defecation urge. Rectal compliance was higher in patients with fecal incontinence than in control subjects, whereas patients with constipation did not differ from control subjects. Regression analysis showed a linear relationship between viscous fluid retention and the maximum tolerable volume and also between viscous fluid retention and rectal compliance. No difference in the ability to retain viscous fluid between male and female control subjects was found; regression analysis of viscous fluid retention in relation to age revealed decreasing volumes with increasing age. Day-to-day variation of the ability to retain viscous fluid was tested in eight persons, and reproducibility was found to be good.

Anorectal pressure gradient in patients with anal incontinence.

Anorectal pressures in patients with fecal incontinence have been investigated. With anal manometry, 34 percent of patients with fecal incontinence had maximal resting pressure and 39 percent had maximal squeeze pressure within the normal range. When a pressure gradient was calculated as the pressure difference between maximal resting pressure and rectal pressuring during filling of a rectal balloon, patients with fecal incontinence could be better distinguished from controls: 20 percent of patients with fecal incontinence had values within the normal range when the rectal pressure at the earliest defecation urge was used (P less than 0.05), and 12 percent had values within the normal range when the rectal pressure at maximal tolerable volume was used (P less than 0.01). Anorectal pressure gradient measurements seem to distinguish patients with fecal incontinence from controls better than maximal resting pressure or maximal squeeze pressure alone.

Relation between electromyography and anal manometry of the external anal sphincter.

Thirteen patients with faecal incontinence and 26 control subjects were studied to investigate whether a quantitative electromyographic (EMG) signal could be correlated to anal manometry. Three different electrodes were used--a concentric needle electrode, a disposable sponge electrode, and a hard anal plug electrode. The maximum amplitude of the EMG recording was used as a quantitative parameter. Linear regression showed significant correlation between EMG and anal manometry with the sponge electrode, both at rest and during squeeze. Significant correlation was also found with the concentric needle electrode during squeeze but not at rest. No correlation was found with the hard anal plug electrode either during squeeze or at rest. Reproducibility studies using the sponge electrode showed acceptable day to day variation. In conclusion, quantitative EMG recordings from a disposable sponge electrode placed in the anal canal correlate well to anal manometry and may be used for assessment of sphincter function, but the hard anal plug electrode cannot be recommended.